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COLUMBIA    UNIVERSITY 

EDWARD  G.  JANEWAY 

MEMORIAL  LIBRARY 


Digitized  by  tine  Internet  Arciiive 

in  2010  witin  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofstomacOOIock 


DISEASES  OF  THE  STOMACH 


INCLUDING 


DIETETIC  AND   MEDICINAL 
TREATMENT 


BY 

GEORGE  ROE  LOCKWOOD,  M.D. 

PROFESSOR    OF    CLINICAL    MEDICINE    IN    THE    COLUMBIA    UNIVERSITY;    ATTENDtNO    PHYSICIAN 
TO    BELLEVUE    HOSPITAL,    NEW    YORK 


ILLUSTRATED  WITH   126  ENGRAVINGS  AND  15  PLATES 


LEA    &    FEBIGER 

PHILADELPHIA    AND    NEW    YORK 
1913 


\ 

Entered  accordin;!  to  the  Act  of  Congress,  in  the  year  1913,  by 

LEA   &   FEBIGER, 
m  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


PEEFACE 


It  has  been  the  author's  intention  to  describe  the  diseases  of  the 
stomach  as  he  has  happened  to  see  them,  and  to  present  these  sub- 
jects from  the  standpoint  of  personal  experience.  For  this  purpose 
series  of  cases  have  been  grouped  and  analyzed  and  the  results  noted, 
whether  or  not  these  results  have  been  in  harmony  with  preexisting 
ideas.  When  the  results  have  been  at  variance  with  the  accepted 
teachings,  the  fact  has  been  noted,  and  opposing  views  given  free 
discussion,  but  no  attempt  has  been  made  to  alter  the  results  of  the 
analyses  of  the  case  histories  because  they  may  seem  strange  and 
unexpected.  Each  series  has  comprised  as  many  cases  as  possible, 
differing  naturally  in  number  according  to  the  frequency  of  the  disease 
under  discussion.  In  the  analyses  of  diseases  of  comparative  rarity, 
the  recorded  cases  have,  as  a  rule,  been  read  in  full  in  the  original 
articles  and  the  statistics  thus  carefully  worked  out.  The  following 
pages,  therefore,  do  not  represent  a  compilation  from  various  authorities, 
brought  together  and  harmonized,  but,  on  the  contrary,  they  reflect 
careful  study  of  conditions  of  disease  from  private  and  hospital  case 
records  and  from  authentic  histories  in  literature. 

The  book  may  be  described,  in  brief,  as  a  fairly  complete  presenta- 
tion of  diseases  of  the  stomach  as  the  result  of  many  years  of  practice 
and  observation  of  this  special  field.  It  is  hoped  that  the  general 
practitioner  may  find  in  it  what  he  needs,  and  that  the  specialist 
may  be  interested  in  the  author's  views  when  they  differ  from  those 
commonly  accepted  hitherto. 

To  many  friends  who  have  helped  and  encouraged  the  author  in  this 
task  he  is  deeply  grateful.  To  Dr.  Albert  R.  Lamb,  of  the  Presby- 
terian Hospital,  he  is  indebted  for  invaluable  assistance  in  the  sections 
on  Pathology  and  for  the  supervision  of  the  photographs  of  pathological 
material.  His  thanks  are  tendered  to  Dr.  Robert  L.  Hutton  for  valu- 
able assistance  in  the  preparation  of  many  of  the  articles.  To  Dr. 
Hoobler  he  is  under  obligations  for  his  assistance  in  the  preparation 
of  the  article  on  Cyclic  Vomiting.  The  sections  on  Radiographic 
Diagnosis  have  been  difficult  to  prepare,  owing  to  radical  differences 
of  opinion  between  some  of  the  leading  radiologists  as  to  the  limita- 


IV  PREFACE 

tions,  or  lack  of  limitations,  of  their  special  art.  ]\Iany  minor  points  in 
radiographic  diagnosis  have  not  been  given  in  the  text  simply  because 
of  differences  at  the  present  time  between  these  experts  as  to  their 
diagnostic  value.  To  Dr.  Busby,  of  the  New  York  Hospital,  and 
Dr.  Le  Wald,  of  St.  Luke's  Hospital,  the  author  desires  to.  express 
his  thanks  for  their  kindness  in  supplying  illustrative  radiographic 
plates.  Acknowledgment  of  the  donor  of  each  plate  is  made  in  the  text. 
Dr.  Edward  Leaming  has  not  only  furnished  many  of  the  plates,  which 
are  severally  acknowledged  in  the  text,  but  also  has  reproduced  the 
plates  from  all  sources,  so  as  to  be  suitable  for  illustration,  and  has, 
furthermore,  by  his  helpful  criticism,  been  of  the  greatest  personal 
service.  To  him  grateful  thanks  are  rendered.  To  Dr.  Bloodgood, 
of  Baltimore,  the  author  is  indebted  for  a  number  of  photographs  of 
pathological  specimens  from  his  laboratory  at  Johns  Hopkins  Hospital. 
To  other  friends,  and  to  those  collaborators  who  have  kindly  allowed 
the  use  of  illustrations  from  their  articles,  an  expression  of  appreciation 
of  their  courtesy  is  due.  Acknowledgment  of  the  source  jof  each 
illustration  is  given  in  the  text. 

G.  R.  L. 

New  York,  1913. 


CONTENTS 


CHAPTER   I 
Acute  Gastritis 17 

CHAPTER   II 

Chronic  Gastritis 42 

CHAPTER   III 

Cirrhosis  of  the  Stomach  (Linitis  Plastica) 76 

CHAPTER   IV 
Acute  and  Chronic  Ulcer 90 

CHAPTER  V 
Erosions  and  Rare  Ulcers 192 

CHAPTER   VI 

Cancer  of  the  Stomach 210 

CHAPTER  VII 

Sarcoma  of  the  Stomach 277 

CHAPTER   VIII 

Benign  Tumors  and  Foreign  Bodies 286 

CHAPTER   IX 

Tuberculosis  and  Syphilis  of  the  Stomach 298 

CHAPTER   X 

Anatomy  of  the  Stomach 309 

CHAPTER   XI 
Acute  Dilatation  of  the  Stomach 333 


vi  CONTENTS 

CHAPTER  XIl 
Pyloric  Spasm  axd  Pyloric  Stenosis 316 

CHAPTER  XIII 

CONGEXITAL    PvLORIC   StEVOSIS 38 1 

CHAPTER  XIV 
Hour-glass  Stomach 392 

CHAPTER   XV 

Diaphragmatic  Herxia — Eventratiox — Volvulus      ....  399 

CHAPTER   XVI 
Gastroptosis 42G 

CHAPTER   XVII 
Hyperacidity 459 

CHAPTER  XVIII 

ACHYLIA 481 

CHAPTER  XIX 
Hypersecretion  (Gastrosuccorrhea  or  "  Reichmann's  Disease")  510 

CHAPTER   XX 

Neuroses 538 

CHAPTER  XXI 

Various  Diseases  and  Their  Gastric  Rel.\tions      ...  .      .     568 


DISEASES  OF  THE  STOMACH 

CHAPTER   I 

ACUTE  GASTRITIS 

ACUTE   CATARRHAL    GASTRITIS 

Although  acute  gastritis  is  undoubtedly  one  of  the  commonest  of 
diseases,  the  number  of  cases  actually  coming  under  the  observation 
of  the  physician  is  relatively  small,  as  in  the  great  majority  of  instances 
the  symptoms  are  either  transient  or  of  such  mild  severity  that  no 
medical  treatment  is  required.  Unfortunatel}^,  however,  the  diagnosis 
of  acute  catarrh  of  the  stomach  is  made  far  more  frequently  than  is 
warranted,  and  often  includes  cases  of  acute  appendicitis,  gall-bladder 
disease,  ulcer,  acute  onset  of  cancer  of  the  stomach,  neuroses,  and 
even  the  gastric  crises  of  tabes.  The  term,  strictly  speaking,  should 
only  be  applied  to  those  cases  of  acute  indigestion  in  which  direct 
evidence  of  gastric  inflammation  exists,  and  not  indiscriminately  used 
to  include  all  temporary  subjective  disturbances  that  follow  dietetic 
errors.  It  is,  however,  extremely  difficult  to  determine,  clinically, 
whether  or  not  a  true  inflammation  exists,  as  pathognomonic  signs  of 
such  are  usually  lacking,  except  in  the  infectious  forms  that  are  the 
result  of  food  poisoning. 

Acute  catarrhal  gastritis  may  be  clinically  divided  into  two  prominent 
types : 

1.  Dietetic  or  simple  gastritis. 

2.  Infectious  gastritis  or  food  poisoning. 

I.  Dietetic  or  Simple  Gastritis. — Etiology. — Among  the  causes  predis- 
posing to  acute  catarrhal  gastritis  may  be  enumerated  lesions  of  the 
heart  or  of  the  liver,  leading  to  chronic  congestion  of  the  stomach. 
Conditions  of  depreciated  health  or  of  fever  that  render  it  difficult  for 
the  stomach  properly  to  digest  its  food,  may  be  considered  as  contribu- 
tory causes,  although  the  influence  of  the  general  condition  of  health 
is  far  less  potent  than  is  ordinarily  supposed.  It  is  said  that  gouty 
individuals  are  liable  to  recurrent  attacks  of  gastric  catarrh. 
2 


18  ACUTE  GASTRITIS 

The  resistance  of  the  stomach  to  inflammation  differs  very  much  in 
different  people — a  fact  which  we  recognize  by  the  use  of  such  terms 
as  "strong  stomachs"  and  "weak  digestions."  There  are  those  whose 
stomachs,  while  equal  to  the  ordinary  daily  task  of  digestion,  are  not 
possessed  of  any  reserve  power,  but  succumb  to  dietetic  errors  to  which 
others  seem  immune. 

There  are,  moreover,  individual  idiosyncrasies  in  which  some  normal 
and  healthy  food  produces  acute  gastric  irritation,  that  cannot  be 
ascribed  to  toxic  effects  or  to  bacterial  invasion.  Thus,  some  persons 
suffer  from  vomiting  and  urticaria  from  eating  fish  in  any  form,  or 
crabs  or  lobsters,  while  in  others,  beef,  pork,  and  game  will  produce  the 
same  unpleasant  results.  It  is  not  to  be  denied,  however,  that  many  of 
these  instances  are  really  cases  of  autosuggestion,  from  subconscious 
impressions  derived  from  some  previous  unpleasant  experience  with 
that  particular  article  of  food.  It  is  probable  that  many  of  these 
so-called  idiosyncrasies  may  be  explained  by  the  recent  theory  of 
anaphylaxis.  ^ 

During  the  earlier  years  of  life  the  chief  cause  is  found  in  dietetic 
errors.  In  old  age  the  tendency  to  portal  stasis  renders  the  ailment 
relati\ely  common.  In  these  aged  subjects  the  effect  of  exposure  to 
cold  may  be  sufficient  to  induce  an  attack,  by  causing  a  sudden  increase 
in  the  internal  congestion.  Among  other  predisposing  causes  in  elderly 
persons  may  be  mentioned  the  frecjuency  with  which  achylia  is  found 
in  those  aged  over  sixty  years.  The  eft'ect  of  such  deficiency  of  gastric 
digestion  in  inducing  an  attack  of  acute  gastric  catarrh  can  readily  be 
appreciated. 

A  predisposition  to  gastric  catarrh  is  present  during  infectious 
disease,  intestinal  parasites,  acute  renal  or  cardiac  disease,  and- often 
accompanies  acute  tuberculosis,  masking  the  primary  disease  in  many 
cases  in  which  the  pulmonary  symptoms  and  physical  signs  are  not 
evident. 

Infection  of  gastric  mucous  membrane  as  the  result  of  bacterial 
invasion  is  common  enough.  Gastritis  due  to  streptococcus,  typhoid 
bacillus,  or  pneumococcus  is  generally  well  recognized.  These  bacteria 
usually  obtain  entrance  by  the  blood  or  lymph  channels,  and  the  gas- 
tritis is  a  secondary  manifestation  of  the  original  infective  disease. 
Pneumococcus  infection  may  occur  as  a  primary  form  of  invasion,  and 
may  give  rise  to  gastric  ulceration. 

Exciting  Cause. — The  commonest  exciting  cause  for  acute  gastritis 
is  dietetic  error.    This  may  occur  in  a  great  variety  of  ways. 

1.  Errors  in  Food. — The  food  may  be  too  rich,  or  may  be  improperly 
cooked.  Overeating  is  one  of  the  most  frequent  causes.  Drinking  of 
cold  liquids  or  of  ice-cream  soda  when  overheated  is  a  common  cause 


ACUTE  CATARRHAL  GASTRITIS  19 

for  acute  gastric  catarrh,  as  is  also  overindulgence  in  alcohol.  Attacks 
in  children  commonly  follow  the  eating  of  unripe  fruit.  The  influence 
of  idiosyncrasy  in  diet  has  already  been  alluded  to. 

2.  Errors  in  Eating. — Food  may  be  proper  and  wholesome,  but  if 
imperfectly  masticated,  or  bolted,  or  eaten  when  the  patient  is  over- 
tired or  under  nervous  strain,  gastric  catarrh  may  ensue. 

The  form  of  gastritis  that  follows  the  ingestion  of  infected  food  is 
described  under  a  separate  heading. 

Swallowed  secretions  from  the  nasopharynx  or  bronchi  may  act  as 
infective  agents,  especially  potent  in  this  regard,  being  decomposed 
pus  from  gangrene  of  the  lung  and  the  alveolar  secretions  of  Rigg's 
disease. 

Pathology. — No  one  has  had  a  better  opportunity  of  studying  the 
gross  appearance  of  the  stomach  in  this  condition  than  William  Beau- 
mont in  the  course  of  his  prolonged  experiments  on  Alexis  St.  Martin. 
He  saw  the  condition  as  it  existed  in  the  living  subject  without  the 
postmortem  changes  which  render  a  correct  appreciation  of  the  true 
appearance  so  difficult.  Morbid  changes,  following  errors  in  eating 
and  drinking,  presented  themselves  several  times  in  St.  Martin's 
stomach  during  Beaumont's  investigations.  He  thus  describes  an 
attack  of  acute  gastritis: 

"The  coats  of  the  stomach  have  not  appeared  in  their  usual  healthy 
condition  for  several  days  past— the  color  darker;  mucous  coat  unequal, 
some  patches  of  a  purplish  color  with  aphthous  edges,  surface  inclined 
to  be  dry,  very  little  secretion  of  gastric  juice,  digestion  slower  and 
less  perfect  than  usual,  bowels  inactive." 

In  another  place,  under  similar  conditions,  he  speaks  of  the  "large 
proportion  of  thick,  ropy  mucus"  mixed.with  the  stomach  contents. 

This  practically  represents  our  conception  of  the  condition  at  the 
present  time.  The  stomach  is  not  altered  in  size  or  shape.  The  changes 
are  most  marked  at  the  pylorus,  the  region  which  bears  the  brunt  of 
the  digestive  process.  There  is  diffuse  or  patchy  redness,  with  swelling 
of  the  mucous  membrane.  At  times,  there  may  be  minute  hemor- 
rhages or  superficial  erosions.  An  excessive  amount  of  tenacious 
mucus,  occasionally  of  brownish  tinge  from  extravasation  of  blood, 
covers  the  surface.  The  amount  of  gastric  juice  secreted  is  much  less 
than  normal,  and  it  contains  a  diminished  amount  of  hydrochloric 
acid. 

Microscopically  the  changes  are  confined  almost  entirely  to  the 
mucosa.  The  glandular  epithelium  is  swollen  and  granular,  and  it  is 
difficult  to  distinguish  between  the  chief  and  parietal  cells.  Goblet 
cells  are  numerous.  The  capillaries  and  small  vessels  are  dilated  and 
there  may  be  many  red  blood  cells  scattered  through  the  mucosa,  with 


20  ACUTE  GASTRITIS 

some  round-celled  infiltration  between  the  tubules  and  extending  into 
the  submucosa,  which  is  often  edematous.  The  solitary  lymph  follicles 
are  often  swollen,  and  leukocytes  may  be  present  in  the  intertubular 
tissue.  The  lumina  of  the  glands  contain  debris  of  degenerated  cells. 
Leukocytes,  red  blood  cells,  and  desquamated  epithelial  cells,  in,  various 
stages  of  degeneration,  are  mixed  with  the  stringy  mucus  covering  the 
surface. 

Symptoms. — The  symptoms  begin  usually  within  a  few  hours  after 
the  exciting  cause,  but  may  be  delayed  for  twenty-four  to  thirty-six 
hours. 

In  the  mild  cases,  nausea  and  vomiting  may  be  absent,  the  chief 
complaints  being  headache,  mental  depression,  loss  of  appetite  and 
coated  tongue.  The  bowels  may  be  constipated  or  there  may  be  diar- 
rhea.   An  example  of  such  an  attack  is  as  follows: 

]\Iale,  aged  forty-two  years. 

One  week  ago  he  went  to  a  country  hotel,  where  he  ate  heartily  of 
badly  cooked  food.  Next  morning  he  awoke  with  a  headache,  xjoated 
tongue,  and  complete  anorexia.  He  felt  depresesd  and  miserable.  He 
remained  in  bed  two  days  on  a  milk  diet,  and  gradually  improved, 
although  his  appetite  was  a  long  time  in  returning.  His  bowels,  though 
previously  regular,  became  constipated  and  mo\'ed  only  after  taking 
calomel. 

In  the  more  severe  cases  the  patient  com])lains  of  uneasy  feelings  in 
the  stomach  that  merge  into  nausea.  Vomiting  soon  occurs,  the 
vomited  matters  consisting  of  the  contents  of  the  stomach,  mixed  with 
mucus,  and  usually  offensive  from  the  presence  of  organic  acids.  There 
is  almost  invarial)ly  a  reduction  or  even  an  absence  of  hydrochloric 
acid,  although  very  rarely  this  form  of  acidity  may  be  normal  or 
excessive.  Acute  gastritis,  with  a  total  acidity  of  40  or  over,  should 
arouse  our  suspicions  that  more  than  simple  acute  catarrh  is  present. 
Lactic  acid  is  rarely  present. 

The  tongue  is  usually  dry  and  coated,  and  there  is  apt  to  be  thirst. 
A  diffuse  tenderness  may  be  elicited  by  ])ressure  on  the  ei)igastrium. 

In  ordinary  gastritis  the  vomitiiuj  usuaUy  ceases  as  soon  as  the  stomach 
is  emptied,  and  is  repeated  only  after  ingestion  of  food.  When  the 
vomiting  is  prolonged,  the  diagnosis  of  gastritis  should  not  be  made 
without  reservation. 

Watery  vomiting  or  the  vomiting  of  large  (luantities  of  fluid  con- 
taining free  hydrochloric  acid  does  not  occur  in  acute  gastritis,  but 
suggests  some  form  of  pyloric  closure,  commonly  seen  with  ulcer,  more 
rarely  with  cancer  of  the  stomach. 

Pain  as  a  sym|)toni  of  acute  gastritis  is  not  usually  observed  exce])t 
in  the  attacks  that  follow  a  gross  dietetic  error.    In  these  cases  cramp- 


ACUTE  C'ArARRHAL  GASTRITIS  21 

like  pains  in  the  epif);astrium  may  occur,  later  becominjij  more  generally 
distributed  over  the  lower  abdominal  zones,  as  the  undigested  ingesta 
enter  the  intestinal  tract.  This  is  a  true  "stomach-ache"  common  in 
childhood.     The  following  case  may  be  given  as  an  example: 

S.  (j.,  male,  aged  twenty-one  years.    Admitted  May  8,  1909. 

Present  History. — Always  well.  On  the  day  of  admission  he  started 
with  friends  to  "  enjoy  a  day  in  the  city."  After  visiting  several  saloons 
and  eating  immoderately  of  pickles  and  cabbage,  he  began  to  feel 
nauseated  and  to  vomit  frequently.  He  had  cramp-like  pains  in  the 
epigastrium. 

Physical  Examination. — Tenderness  in  the  epigastrium  was  present 
with  slight  rigidity  over  the  upper  right  rectus.  Otherwise  negative. 
He  remained  in  the  hospital  for  three  days  and  was  then  discharged 
cured. 

Pain  other  than  this  does  not  appear  as  a  symptom  of  acute  gastritis, 
despite  the  fact  that  many  writers  mention  pain  of  a  burning  or  lanci- 
nating character  as  not  uncommon. 

Flatulence  does  not  occur  unless  it  be  a  preexisting  symptom.  The 
urine  is  usually  scanty,  highly  colored,  and  cloudy  from  the  precipitation 
of  urates. 

In  mild  cases  the  temperature  is  not  usually  elevated,  although 
predisposition  to  fever  is  often  peculiar  to  the  individual,  and  the 
tendency  to  develop  fever  from  slight  causes  may  last  through  adult 
life.  The  temperature  may  be  slightly  elevated  in  the  more  severe 
cases. 

In  children,  fever  may  be  a  prominent  symptom  and  may  be  con- 
tinuous for  a  number  of  days.  To  this  condition,  Eustace  Smith  has 
applied  the  term  "acute  febrile  gastritis  of  children." 

Prostration  and  headache  are  common,  but  are  not,  as  a  rule,  severe 
except  with  food  infections.  There  may  be  various  forms  of  skin 
eruptions,  chiefly  of  a  roseolar,  erythematous,  or  urticarial  character, 
but  these  are  rare,  except  after  food  poisoning,  especially  by  shell-fish. 

Diarrhea  often  appears  at  the  onset,  and  may  be  due  either  to 
increased  intestinal  peristalsis  or  to  a  complicating  ileocolitis.  When 
the  stomach  alone  is  involved,  constipation  is  the  rule. 

As  the  attack  subsides,  symptoms  of  atony  often  appear,  and  may 
protract  the  course  of  the  disease  several  days  or  even  weeks.  There 
is  lack  of  appetite  or  even  nausea,  though  vomiting  is  rare.  A  slight 
amount  of  gastric  flatulence  may  be  present  in  this  atonic  stage.  These 
symptoms  are  transient,  however,  and  no  sequelae  result. 

Duration. — The  duration  of  the  attack  is  short,  the  acute  stage 
rarely  extending  over  one  or  two  days,  although  it  may  be  a  week  or 
so  before  the  patient  regains  his  appetite  and  considers  himself  well. 


22  ACUTE  GASTRITIS 

Cases  with  nausea  and  \'omiting  extending  over  two  days  must  be 
regarded  with  suspicion.  Recurrences  are  not  common,  except  in 
those  whose  life  history  shows  a  constant  repetition  of  attacks  from 
individual  predisposition,  or  in  those  who  repeatedly  subject  them- 
selves to  gross  dietetic  errors.  Frequent  recurrences  without  assignahle 
cause  should  throw  doubt  upon  the  diagnosis. 

Diagnosis. — The    extreme    frequency    in    which    acute    appendicitis 
first  manifests  itself  by  pain  or  distress  in  the  epigastrium  and  vomiting 
should  always  be  remembered,  and  a  careful  examination  should  be 
made,  even  in  cases   that   seem   straightforward   examples  of  acute- 
gastric  catarrh.    The  blood  count  is  of  value  in  doubtful  cases. 

Exacerbations  of  chronic  appendicitis  may  be  responsible  for  many 
cases  of  apparent  gastritis,  with  pain,  nausea,  and  vomiting,  often  asso- 
ciated with  diarrhea.  This  is  especially  the  case  in  children  in  whom 
recurring  bilious  attacks  with  nausea  and  vomiting  often  cease  after  a 
frank  attack  of  inflammation  of  the  appendix,  and  its  subsequent 
removal. 

Ulcer  of  the  stomach  is  often  erroneously  diagnosticated  as  gas- 
tritis, especially  when  the  former  disease  assumes  the  vomiting  type. 
The  vomiting  of  ulcer  is,  however,  more  protracted  than  that  of  gas- 
tritis, is  associated  with  definite  pain,  and  assumes  in  many  instances 
the  acid  watery  type  of  vomiting  which  is  never  seen  in  gastric  catarrh. 
jMany  cases  of  cancer  begin  with  vomiting,  and  it  is  suspicious  of 
malignancy  if,  during  the  age  of  cancer  incidence,  protracted  vomiting 
occurs  without  an  apparent  exciting  cause,  especially  if  the  patient 
has  recently  been  losing  somewhat  in  flesh  and  strength. 

The  gastric  symptoms  of  gall-bladder  disease  are  often  erroneously 
diagnosticated  as  gastritis.  Physical  examination  shows  the  tenderness 
located  over  the  gall-bladder  area,  which  should  prevent  error  in 
diagnosis  between  these  two  conditions.  It  must  be  remembered  that 
many  of  the  acute  infectious  diseases  may  begin  with  vomiting,  as  an 
initial  symptom,  and  that  one  should  be  guarded  in  expressing  a  definite 
opinion  too  soon  in  the  course  of  the  disease,  especially  in  children. 

In  every  case  of  suspected  gastritis,  pregnancy,  uremia,  and  the 
gastric  crises  of  tabes  must  be  excluded.  Cyclic  vomiting  with  acidosis 
in  children  should  not  be  forgotten. 

Treatment. — But  little  medical  treatment  is  recpiired  in  the  majority 
of  cases  of  acute  gastritis.  l{est  in  bed  with  abstinence  from  food 
until  the  nausea  has  disappeared  is  usually  sufficient  to  effect  a  speedy 
cure.  When  there  has  been  a  gross  dietetic  error,  and  vomiting  has 
not  apparently  Ix'cii  sufficient  to  empty  the  stomach,  emesis  may  be 
induced  either  !>>  draughts  of  salt  water  combined  with  the  tickling 
of  the  throat,  or,  esix-cially  in  hosjiital  cases,  hypodermics  of  apomor- 


ACUTE  CATARRHAL  GASTRITIS  23 

phine  (grain  |)  may  be  employed.  Free  emesis  usually  shortens  the 
attack  and  prevents  intestinal  complications.  If  the  patient  be  accus- 
tomed to  the  stomach-tube,  the  stomach  may  be  washed  out  by  the 
ordinary  method.  A  tube  of  fairly  large  caliber  should  be  used  to 
prevent  blocking  of  the  lumen  by  particles  of  undigested  food. 

If  the  patient  is  not  seen  during  the  early  part  of  the  attack,  it  is 
generally  wise  to  administer  a  mild  laxative,  either  calomel,  or  if  the 
stomach  is  in  a  receptive  mood,  castor  oil,  magnesium  citrate,  or  other 
saline  aperient.  If  intestinal  cramps  and  flatulency  are  present  a  high 
saline  enema  should  be  given.  The  nausea  is  usually  relieved  promptly 
after  the  taking  of  food  has  been  discontinued.  Nausea  may  also  be 
relieved  by  small  doses  of  cerium  oxalate,  or  by  minim  doses  of  car- 
bolic acid  with  or  without  diluted  hydrocyanic  acid.  vSuch  a  prescrip- 
tion may  be  given  as  follows: 

I^ — Acid,  carbolic,  95  per  cent., 

Acid,  hydrocyanic,  dil aa     TTLxyj 

Mist,  cretse  comp ad     §ij — M. 

Sig. — Teaspoonful  in  a  little  water  every  hour  for  four  doses. 

The  following  may  also  be  employed: 

I^ — Acid,  carbolic.  (Calvert's), 

Glycerin aa     5ss 

Aq.  laurocerasi 5  3 

Aq.  menth.  pip ad     giv — M. 

Sig. — Teaspoonful  in  a  little  water  every  two  hours. 

The  thirst  may  be  controlled  by  cracked  ice  slowly  melted  in  the 
mouth,  or  by  ^-dram  doses  of  creme  de  menthe  in  shaved  ice,  a  remedy 
which  is  furthermore  of  great  value  in  relieving  nausea  and  vomiting. 

It  is  rarely  necessary,  except  in  the  food-poisoning  cases,  to  continue 
abstinence  from  food  after  twenty-four  to  thirty-six  hours.  As  soon 
as  the  condition  of  the  stomach  will  permit,  peptonized  milk  or  milk 
with  lime  water,  or  cerium  oxalate,  may  be  given.  In  those  to  whom 
milk  is  distasteful,  hot  broths  may  be  given.  Solid  food  should  not 
be  given  until  nausea  has  ceased. 

During  the  stage  of  atony  that  often  follows  an  attack  the  bitter 
stomachics  are  of  service.  Of  special  value  is  the  tincture  of  nux 
vomica  in  10-minim  doses  before  meals,  or  the  tincture  of  physostigma 
in  similar  doses.  As,  moreover,  a  condition  of  diminished  gastric 
acidity  usually  follows  an  attack,  diluted  hydrochloric  acid  with 
the  meals  may  be  of  service.  This  after-treatment,  together  with  the 
limitation  of  liquids  at  the  time  of  meals,  and  with  a  carefully  selected 
bland  diet,  is  to  be  continued  until  food  is  taken  again  with  relish. 


24  ACUTE  GASTRITIS 

II.  Infectious  Gastritis  (Food  Poisoning;  Ptomain  Poisoning).^ 
Etiology. — Infectious  gastritis  may  be  induced  through  infected  meat, 
fish  or  milk,  or  })y  vegetable  poisons.  Bacteria  are  largely  responsible 
for  the  poisoning  which  follows  the  ingestion  of  certain  food,  because 
they  have  been  identified  in  a  large  proportion  of  epidemics  of  food 
poisoning  that  have  been  scientifically  investigated.  The  poisoning 
may  be  due  to  organisms  that  are  present  before  death  in  the  tissues 
of  the  animal  from  which  the  food  was  derived,  or  to  those  that  have 
subsequently  gained  access  to  such  food. 

In  most  instances  the  infected  food  has  been  free  from  all  objection- 
able odor  and  taste,  and,  contrary  to  the  accepted  belief,  it  is  rather 
rare  that  the  ordinary  putrefactive  organisms  or  their  products  are 
capable  of  causing  poisoning  in  man. 

The  most  important  infecting  organism  is  the  Bacillus  enteritidis,  a 
bacillus  intermediate  between  the  Bacillus  typhosus  and  the  Bacillus 
coli  communis,  first  described  by  Gartner  in  1858,  and  often  associated 
with  his  name. 

The  epidemic  investigated  by  Gartner  affected  58  of  93  persons 
who  had  eaten  the  meat  of  an  ox  that  had  been  killed  because  it  had 
diarrhea.  Examination  of  the  meat  showed  that  its  capillaries  con- 
tained bacilli  identical  with  those  found  in  the  tissues  of  the  fatal  cases. 

The  causative  role  played  by  bacteria  in  the  production  of  gastro- 
intestinal catarrh  is  shown  by  an  interesting  experiment,  made  by 
Poels  and  Dhont. 

A  healthy  ox  was  inoculated  with  a  small  quantity  of  pure  culture 
of  a  variety  of  Bacillus  enteritidis  in  the  jugular  vein;  twenty-six 
minutes  afterward  it  was  killed  and  partially  bled  out.  On  bac- 
terial examination  a  few  colonies  were  obtained  from  the  spleen  and 
liver.  None  were  found  in  cultures  from  the  flesh;  a  few  bacilli  were 
present  in  the  blood.  After  keeping  a  piece  of  the  flesh  at  20°  C.  for 
seventy-two  hours  the  bacilli  had  become  more  abundant.  The  rest 
of  the  meat  had  been  kept  at  a  lower  temperature,  not  over  5°  C;  in 
this  scanty  l)acilli  were  detected.  "After  we  had  assured  the  workers 
in  the  slaughter-house  that  we  were  convinced  from  the  smallness  of 
the  number  of  bacilli  present  in  the  muscle  that  the  danger  of  eating 
the  meat  could  not  be  very  great,  and  that  it  would  probably  cause 
only  slight  diarrhea,  53  persons  resolved  to  eat  it.  Of  these  53,  15 
became  ill  in  consequence;  headache,  gastro-intestinal  catarrh,  and 
abdominal  pain  came  on  in  from  twelve  to  eighteen  hours;  in  some 
there  was  severe  diarrhea." 

The  serum  of  typhoid  fever  agglutinates  the  Gartner  bacillus,  showing 
a  certain  kinship  between  the  two  varieties. 

Bacillus  enteritidis  in  milk  is  not   uncommon.      Klein  found  this 


ACUTE  CATARRHAL  GASTRITIS  25 

organism  in  ten  out  of  thirty-nine  samples  of  milk.  As  boiling  does 
not  destroy  the  toxin,  the  ordinary  methods  of  sterilization  do  not 
render  the  milk  harmless. 

Other  bacilli,  closely  resembling  Bacillns  enteritidis  morphologically, 
but  differing  from  it  in  agglutinative  properties,  have  been  described 
by  other  observers. 

A  paratyphoid  bacillus  was  found  by  Trautmann  to  be  the  cause 
of  one  outbreak,  and  in  one  epidemic  the  Bacillus  typhosus  was  found 
to  be  the  existing  cause.  In  this  instance  the  meat  was  taken  from  a 
cow  with  a  splenic  abscess  that  was  found  to  contain  pure  culture  of 
this  organism. 

In  many  instances  infection  by  Bacillus  coli  communis  has  been  the 
cause,  less  frequently  the  Bacillus  proteus. 

Special  mention  must  be  made  of  infection  by  the  Bacillus  botulinus, 
an  anaerobic  bacillus  identified  by  von  Ermengem  in  1895,  and  found 
in  diseased  ham.  This  infection  runs  somewhat  a  different  course 
from  the  Gartner  bacillus  groups,  and  usually  follows  ingestion  of 
diseased  sausage  meat.  To  this  form  of  poisoning  the  name  "botulism" 
is  frequently  applied.  The  Bacillus  botulinus  does  not  seem  to  develop 
to  any  extent  in  the  human  body,  so  that  the  symptoms,  properly 
speaking,  are  not  due  to  an  infection,  but  to  an  intoxication  by  the 
toxin  produced  by  the  germ  in  meat. 

In  the  case  of  Bacillus  botulinus,  the  toxins  are  readily  destroyed 
by  boiling,  but  in  the  case  of  Bacillus  enteritidis  the  soluble  products 
are  not  thus  affected,  and  hence  meat  containing  such  may  be  injurious 
even  after  it  has  been  cooked. 

According  to  Trautmann,  food  poisoning  represents  the  acute, 
whereas  paratyphoid  fever  infection — etiologically  due  to  the  same 
factor  and  having  the  same  agglutinative  reactions — represents  the 
subacute  type  of  infection. 

Toxins  of  which  tyrotoxicon,  found  in  various  milk  products,  such 
as  ice-cream,  custard,  and  cheese,  by  Vaughan  is  an  example,  may 
be  the  cause  for  acute  gastro-intestinal  irritation.  A  variety  of  sub- 
stances belonging  to  poisonous  albumins  have  been  isolated,  but  about 
these  very  little  is  accurately  known. 

Fish  are  infected  by  the  same  bacteria  as  meats.  The  roe  of  certain 
fish  at  spawning  season  is  also  poisonous  to  man.  This  is  especially 
the  case  with  Spanish  mackerel. 

Oysters  are  commonly  infected  by  contaminated  water  in  which 
they  are  placed  to  whiten  them  and  to  render  them  more  palatable. 

The  ingestion  of  certain  shell-fish,  such  as  crabs  and  lobsters,  are 
often  followed  in  certain  individuals  by  an  attack  of  severe  gastritis, 
which  is,  however,  hardly  to  be  considered  toxic  in  character. 


26  ACUTE  GASTRITIS 

Symptoms. — The  symptoms  of  food  infection  are  those  of  a  severe 
gastro-enteritis  associated  with  those  of  a  more  or  less  intense  toxemia. 
The  intensity  of  the  symptoms  varies  according  to  the  quantity  of  the 
infecting  agent  that  is  taken,  its  virulence,  and  the  susceptibility  of 
the  patient.  The  result  may  be  anything  from  a  slight  passing  illness, 
to  a  severe  or  a  rapidly  fatal  attack.  The  onset  may  appear  within  a 
few  minutes  of  the  ingestion  of  the  infected  food,  or  may  be  delayed 
twenty-four  to  thirty-six  hours. 

Gastro-intestinal  symptoms  consist  of  nausea,  vomiting,  and  abdomi- 
nal pain.  The  vomiting  is  usually  severe  and  frequent,  and  persists 
long  after  the  stomach  has  once  been  emptied — quite  a  different' 
picture  from  that  observed  in  the  ordinary  forms  of  acute  gastritis, 
in  which  vomiting  usually  ceases  soon  after  the  stomach  has  once 
been  thoroughly  emptied  of  its  contents.  Nausea  and  retching  are 
severe  and  protracted.  In  rarer  instances  vomiting  is  absent,  the 
sj'mptoms  being  intestinal  in  character. 

Diarrhea  is  usually  present  during  the  early  stages,  and  is  accom- 
panied by  severe  griping  pains.  The  temperature  is  usually  somewhat 
elevated  at  the  early  stages  and  may  be  accompanied  at  its  onset  by 
headache,  pain  in  the  back  and  bones,  and  other  manifestations  of  an 
acute  infection.  The  duration  of  the  febrile  period  is  usually  short, 
although  in  many  instances  fever  may  persist  for  days  or  there  may 
be  recrudescences  from  time  to  time.  In  these  protracted  cases  the 
diagnosis  from  typhoid  fever  or  paratyphoid  may  be  exceedingly 
difficult. 

Herpetic,  urticarial,  or  erythematous  eruptions  are  not  uncommon. 
In  rarer  instances  desquamation  of  the  hands  and  feet  may  occur  a 
number  of  days  after  the  acute  attack.  Widely  spread  petechias  have 
been  observed. 

Marked  prostration  accompanies  even  the  milder  cases,  while  severe 
infections  are  frequently  ushered  in  by  symptoms  of  collapse  that 
may  rapidly  prove  fatal.  In  these  fulminant  cases  the  collapse  may 
appear  before  the  gastro-intestinal  symptoms  have  time  to  develop. 
In  these  cases  the  temperature  is  apt  to  be  subnormal,  the  pupils 
dilated. 

Pneumonic  complications  have  been  noted  in  a  number  of  epidemics. 

The  urine  is  usually  scanty  and  highly  albuminous.  In  some  instances 
there  is  complete  suppression. 

Special  mention  should  be  made  of  the  infection  symptoms  of 
l)otulism.  The  onset  is  usually  delayed  until  twenty-four  to  thirty-six 
hours  after  the  meal,  and  is  ushered  in  by  nausea,  vomiting,  and  severe 
abdominal  pain.  Diarrhea  is  not  as  commonly  observed  as  in  the  cases 
due  to  infection  by  Gartner's  bacilli  or  the  Bacillus  coli  communis. 


ACUTE  CATARRHAL  GASTRITIS  27 

Visual  disturbances  are  observed  in  many  instances,  and  consist  of 
cloudiness  of  vision,  dilatation  of  the  pupil  with  loss  of  reaction  to  light, 
and  ptosis.  Burning  thirst  is  usually  present,  but  the  swallowing  of 
liquids  is  difficult  and  often  leads  to  severe  choking  attacks. 

Complete  a])honia  is  not  uncommon.  The  temperature  is  seldom 
elevated,  and  the  pulse  rarely  rises  above  90. 

Convulsive  movements  of  the  muscles  of  the  extremities  is  com- 
monly observed;  in  severe  cases  there  may  be  opisthotonos.  Muscular 
paresis  may  occur,  and  dysphagia  from  paralysis  of  the  esophagus  has 
been  observed. 

Closely  akin  to  botulism  is  the  clinical  course  observed  in  certain 
cases  of  poisoning  by  methyl  alcohol.  A  remarkable  epidemic  of  the 
latter  character  has  been  recently  described  by  Stadelmann,^  in  which 
the  symptoms  due  to  methylism  seemed  identical  with  those  of  botulism, 
except  that  no  motor  palsies  were  observed.  Some  of  the  victims  died 
before  characteristic  symptoms  could  develop,  for,  unlike  alcohol,  the 
more  deadly  methyl  spirits  do  not  rapidly  intoxicate,  some  twenty- 
four  to  thirty-six  hours  being  necessary  for  the  development  of  the 
syndrome.  In  this  epidemic  130  cases  came  under  Stadelmann's 
observation,  of  whom  58  died. 

Treatment. — The  treatment  of  food  infections  is  that  of  a  severe 
gastro-enteritis  in  addition  to  those  remedies  required  to  combat  the 
depressive  effect  of  the  toxemia. 

The  stomach  should  at  once  be  emptied,  preferably  by  washing  out 
its  contents  by  the  tube.  In  the  event  of  the  stomach-tube  not  being 
at  hand,  emesis  may  be  produced  by  any  of  the  'ordinary  means. 
Apomorphine,  so  commonly  given  in  the  cases  of  single  gastritis, 
should  be  given  with  caution,  if  at  all,  because  of  its  depressing  effect. 

Free  bowel  evacuations  should  be  produced  by  salines,  elaterium, 
or  calomel.  As  these  remedies  take  time  for  the  desired  effect,  or  may 
be  vomited,  colon  irrigations  or  high  enemas  should  be  given  at  the 
earliest  opportunity. 

Collapse  should  be  averted  as  far  as  possible  by  the  judicious  use 
of  hypodermic  stimulation.  Camphor  injections,  caffeine-sodium- 
benzoate,  and  the  preparations  of  digitalis  are  the  most  desirable  forms 
of  such  stimulation.  Strychnine  should  be  given  with  caution  in  the 
cases  that  are  complicated  by  convulsions  or  muscular  contractions. 
Hypodermoclysis  should  be  employed  in  the  collapsed  patients  who 
suffer  from  repeated  vomiting  and  severe  diarrhea. 

Albumen  water,  broths,  and  similar  mild  fluid  may  be  given  after 
nausea  and  vomiting  have  ceased,  but  not  without  caution  even  then, 
as  relapses  from  premature  feeding  are  not  uncommon. 

1  Berlin,  klin.  Woch.,  Janiiaiy  29,  1912. 


28  ACUTE  GASTRITIS 

Convalescence  is  re^jularly  protracted — the  general  strength  is  not 
apt  to  return  for  three  to  six  weeks.  The  general  management  of 
these  cases  of  protracted  convalescence  is  practically  that  of  typhoid 
fever. 

MEMBRANOUS  GASTRITIS   (CROUPOUS  GASTRITIS- 
DIPHTHERITIC  GASTRITIS) 

Etiology. — Membranous  gastritis  due  to  infection  by  the  Klebs- 
Loeffler  bacillus  is  of  rare  occurrence.  Leary  found  but  two  instances, 
of  diphtheritic  infection  of  the  stomach  in  136  cases  of  fatal  diphtheria 
at  the  Boston  City  Hospital.  Primary  invasion  is  still  more  uncommon, 
as  diphtherial  gastritis  is  almost  regularly  secondary  to  a  similar 
invasion  of  the  esophagus,  throat,  or  upper  respiratory  passages. 

The  lesion  may  be  produced  by  infective  agents  other  than  the 
diphtheritic  bacillus.  It  has  t)ccurred  during  the  course  of  typhus 
fever,  tyi)hoid,  puerperal  fever,  pyemia,  and  a  variety  of  other  infections. 

Foulerton^  reports  a  case  secondary  to  quinsy,  in  which  the  infecting 
agents  were  the  pneumococcus  and  the  Bacillus  mesentericus  vulgatus. 
Dieulafoy  reports  similar  cases  due  to  the  dij)lococcus.  Other  observers 
have  found  streptococci  in  the  shreds  of  false  membrane  vomited  by 
the  patient. 

Membranous  gastritis  may  also  occur  when  chemical  irritants  are 
taken  accidentally  or  with  suicidal  intent.  While  no  age  is  exempt, 
the  disease  is  commonly  obser^'ed  in  young  children. 

Pathology. — The  changes  produced  in  the  stomach  in  this  condition 
are  not  essentially  different  from  those  of  diphtheritic  inflammation  of 
other  mucous  membranes. 

The  mucosa  is,  at  first,  the  seat  of  an  acute  inflammation  which 
leads  to  degeneration  and  desquamation  of  the  superficial  epithelium. 
These  degenerated  and  descjuaniated  cells  l)ecome  mixed  with  fibrin, 
leukocytes,  and  red  blood  cells,  all  being  fused  together  into  a  more  or 
less  homogeneous  mass — the  so-called  false  membrane — by  the  process 
of  coagulative  necrosis.  In  the  mild  cases  this  inflammatory  exudate 
rests  upon  a  fairly  well-preserved  mucosa  and  can  be  removed  from  it 
without  much  injury.  When  the  process  is  more  severe  there  is  more 
or  less  extensive  involvement  of  the  mucosa,  so  that  it  is  fused  with 
the  overlying  membrane  and  the  latter  cannot  be  removed  without 
injury  to  the  former. 

(ienerally  the  membrane  occurs  in  irregular  strips  or  patches.  It 
may  iinoKe  only  the  crests  of  the  ruga*.     On  the  other  hand,  cases 

'  Tran.sactions  of  Piithol()fi;i''.'il  Sof-iciy  "f  liondoii,  1902,  p.  2S6. 


MEMBRANOUS  GASTRITIS 


29 


have  been  reported  where  the  inenibrane  formed  a  more  or  less  perfeet 
cast  of  the  interior  of  the  stomach.  The  membrane  is  grayish  in  color 
or  brownish  from  hemorrhage.    The  mucosa  of  the  rest  of  the  stomach 


FlQ.    1 


M 


MM  ( 
S 


;/■:..."•;  ■••-V-     ^^r'  ^f..< 


'■  '.o'v^. 


• '."    ''.'>'. 


Membranous  gastritis.  A,  membrane,  adherent  to  the  mucosa  at  the  left  and  dipping  down  into 
it  at  B.  To  the  right  the  membrane  has  separated  from  the  mucosa  and  appears  coiled  upon  itself; 
M,  mucosa  showing  dilated  vessels  X,  X,  X,  and  cellular  infiltration  to  the  right;  MM,  muscularis 
mucosae;  S,  submucosa;  Y,  muscularis. 


30  ACUTE  GASTRITIS 

is  congested,  and  the  gastric  functions  are  even  more  markedly  altered 
than  in  other  forms  of  acute  inflammation  of  the  stomach. 

There  may  be  hemorrhage,  generally  slight  in  amount,  from  separa- 
tion of  the  membrane.  Necrosis  and  suppuration  may  occur,  with 
extensive  ulceration.  However,  as  the  disease  is  practically  only 
seen  in  those  already  critically  ill  from  some  otl>er  aft'ection,  death 
usually  ensues  before  such  sequelae  have  time  to  develop. 

Symptoms. — Occurring  usually  as  a  late  complication  of  severe 
infectious  diseases,  the  superimposed  infection  of  the  stomach  rarely 
furnishes  any  additional  features  to  the  original  clinical  course  of  the 
primary'  disease.  There  may  be  nausea  and  vomiting,  but  they  are' 
rarely  sufficiently  intense  to  attract  attention  to  the  gastric  compli- 
cation. There  is  nothing  characteristic  about  the  vomiting  during  the 
earlier  stages  of  the  malady.  As  the  disease  progresses,  however,  bits 
and  shreds  of  the  false  membrane  may  be  found  in  the  vomited  matters, 
and  may  furnish  a  clue  to  the  underlying  cause  for  the  gastric  com- 
plaint. The  presence  of  false  membrane  in  the  vomited  matters  is 
not,  however,  pathognomonic  of  membranous  gastritis,  as  membranous 
shreds  may  have  their  origin  in  the  esophagus  or  throat,  or  be  swallow^ed 
from  a  source  higher  up  than  the  stomach,  and  then  ejected  from  the 
stomach.  Pus  cells  are  usually  found  in  the  vomitus.  During  the 
stage  of  loosening  of  the  membrane,  hemorrhage  may  occur,  usually 
insignificant  in  amount,  although  large,  even  fatal  hemorrhages  may 
occur. 

Prognosis. — Prognosis  is  exceedingly  grave.  The  gastric  inflamma- 
tion is  not  only  serious  in  itself,  but  occurring  as  it  usually  does  during 
the  course  of  a  primary  infective  disease  of  sufficient  virulence  to 
show  a  tendency  to  invade  other  parts  of  the  body,  the  infection 
of  the  stomach  is  an  additional  pathological  burden  for  the  enfeebled 
system  to  carry.  The  pneumococcus  infection  seems  generally  less 
virulent  than  other  formsr  of  bacterial  invasion.  The  prognosis  of  the 
diphtheritic  form  is  more  favorable  when  antitoxin  treatment  is  given 
early.  The  disease  is  so  rare  and  so  seldom  diagnosticated  that  the 
actual  percentages  of  mortality  cannot  be  given. 

Treatment. — Treatment  is  directed  toward  the  gastritis  and  toward 
the  primary  disease.  The  treatment  of  the  gastric  symptoms  are 
those  ordinarily  adopted  in  every  severe  case  of  gastritis  from  what- 
ever cause  it  might  arise.  The  primary  disease  is  to  be  treated  in 
accordance  with  established  usages.  Bacterial  vaccines  may  be  given, 
accorrling  to  the  finding  and  identification  of  the  infective  organisms  in 
the  false  membrane,  but  such  vaccines  unfortunately  have  to  be  given 
from  stock  preparations,  as  there  is  no  time  in  each  individual  instance 
to  work  out  the  autogenous  preparation. 


PHLEGMONOUS  GASTRITIS  31 

PHLEGMONOUS    GASTRITIS    (ACUTE   INTERSTITIAL   GASTRITIS) 

The  term  phlegmonous  gastritis  is  used  to  characterize  those  cases 
of  inflammation  of  the  stomach  in  which  the  gastric  submucosa,  and 
to  lesser  extent  the  mucous  and  serous  coats  are  uniformly  or  focally 
infiltrated  with  pus.  The  disease  is  quite  uncommon,  the  number  of 
reported  cases  being  at  the  present  time  about  one  hundred.  Men  are 
more  frequently  affected  than  women,  in  the  proportion  of  three  to 
one. 

Of  91  cases  reported  by  Robertson  in  1907,  61  were  males,  19  were 
females,  while  in  eleven  the  sex  was  not  mentioned. 

About  one-half  of  the  cases  have  occurred  in  day  laborers — a  class 
especially  addicted  to  the  abuse  of  alcohol  and  to  excesses  in  eating, 
which  tend  to  injure  the  lining  membrane  of  the  stomach.  Alcohol 
may  be  regarded  as  a  predisposing  factor,  although  a  history  of  alcohol- 
ism was  only  obtained  in  14  out  of  91  cases  reported.  Adams,  in  his 
reviewed  cases,  admits  an  alcoholic  history  in  at  least  25  per  cent,  of 
patients,  although  some  have  estimated  that  one-half  of  all  cases  occur 
in  those  addicted  to  drink. 

The  disease  is  not  limited  to  any  particular  age,  the  youngest  patient 
afflicted  being  ten  years  of  age,  the  oldest  eighty-five  years.  The 
majority  of  cases  have  occurred  during  the  mid-period  of  life. 

Etiology. — The  primary  cause  is  always  microbic,  the  infection 
occurring  either  locally,  through  abrasions,  or  defects  in  the  mucous 
membrane,  or  the  invading  germs  may  obtain  entrance  to  the  wall  of 
the  stomach  through  the  blood  current  in  various  forms  of  septic 
disease. 

Local  infections  of  the  stomach  wall  by  pus-producing  germs  may 
occur  through  solutions  of  continuity  of  the  mucous  membrane,  as 
in  ulcer  or  cancer,  or  may  follow  operations  upon  the  w^all  of  the 
stomach  itself.  In  17  out  of  91  cases  the  disease  w^as  preceded  by 
chronic  ulceration  of  the  stomach.  Solutions  of  continuity  of  the 
mucous  membrane  may  also  be  produced  by  caustic  agents,  such  as 
oil  of  turpentine  or  oxalic  acid,  or  even  by  the  use  of  drugs  that 
cause  intense  inflammation  of  the  mucosa.  Klieneberger  has  reported 
one  case  that  followed  a  dose  of  45  grains  of  potassium  iodide,  in  a 
patient  who  had  not  previously  suffered  from  indigestion. 

Abrasions  of  the  mucous  membrane  caused  by  the  contact  of  sharp, 
hard,  scratchy  substances  introduced  in  the  food  may  cause  defects  in 
the  mucous  membrane,  admitting  virulent  bacteria.  It  may  be  impos- 
sible to  find  the  point  of  entrance  at  the  autopsy,  but  it  is  obvious  that 
the  pathology  of  infection  lies  through  some  abrasion  of  the  mucous 
membrane,  which  cannot  be  demonstrated  after  death. 


32 


ACUTE  GASTRITIS 


Infections  through  the  bk:)od  current  may  occur  in  any  pyemic 
condition.  It  Avas  formerly  a  frequent  complication  of  puerperal 
fever,  and  was  especially  marked  in  certain  epidemics  of  which  the 
epidemic  of  puerperal  sepsis  occurring  in  Prague  in  1847  is  perhaps 
the  best  example. 

Fia.  2 


■^.A. 


Mucosa  sliowing  exten- 
sive infiltration  of  inter- 
glandular  stroma  with  poly- 
morphonucloar  leukocytes. 
Destruction  of  lower  ends 
of  glands  and  the  destruc- 
tion of  glandular  elements 
in  the  more  superficial  por- 
tion by  the  inflammatory 
exudate. 


Submucosa  thickened, 
edematous,  and  infiltrated 
with  leukocytes  and  fibrin- 
ous exudate. 


In  the  91  cases  rej)orte(l  by  Robertson,  1 1  followed  the  ingestion  of 
improper  food  or  j)()isons;  3  cases  followed  operations  on  the  stomach; 
2  occurred  in  pyemia,  and  2  others  followed  trauma.  In  1  case  the 
disease  followed  ])urulent  infiannnation  of  the  esophagus. 

Pathology.  In  the  majority  of  cases  the  invading  germ  has  been 
the  streptococcus,  often  associated  with  the  colon  bacillus.  Infection 
by  the  pneumococcus  is  not  unconnnon.  In  less  frequent  cases  any 
one  of  the  pyogenic  organisms  may  be  found. 


PHLEGMONOUS  GASTRITIS  33 

Phlegmonous  gastritis  occurs  in  a  diffuse  and  in  a  circumscribed 
form . 

Diffuse  Form. — The  diffuse  form  occurs  in  SO  per  cent,  of  all  cases, 
and  may  affect  the  whole  area  of  the  stomach,  or  only  a  part,  the 
pyloric  portion  being  the  most  frequently  affected  The  wall  of  the 
stomach  is  greatly  thickened,  often  attaining  a  depth  of  five  or  six 
times  that  of  the  normal.  It  occasionally  attains  a  thickness  even 
greater  than  this. 

Fig.  3 


|iin|ini|iiii|i!ii|iiii|iiiiiiiiiiiiii{iii{|iiiniir 


'  |iin|ini|iiii|i!ii|iiii|iiiiii 
o'm-m   /      2      ?      -  :> 

0       INCHES  ,  2 

1 1 1 1 1 1 1  i  1 1 !  1 !  1 1 1 1 1 ! .  i . 1 1 1 ! !  1 1 1 1 1 T) ! 

Phlegmonous  gastritis.  Section  through  stomach  wall.  The  mucous  membrane  is  seen  much 
thickened  at  M,  and  with  the  muscularis  mucosae  on  cross-section  at  MM.  The  greatly  thickened 
submucosa  which  is  edematous  and  infiltrated  with  pus  is  shown  at  5.  a,  muscularis.  (From  the 
Pathological  Museuna,  Columbia  University,  New  York.) 

The  essential  lesion  is  a  purulent  infiltration  of  the  submucous  coat, 
which  is  greatly  thickened  and  of  a  gelatinous  or  edematous  appear- 
ance, or  even  containing  channels  or  foci  of  liquid  pus.  These  changes 
are  nearly  always  more  marked  in  the  pyloric  half  of  the  stomach,  and 
usually  cease  abruptly  at  the  pyloric  ring. 

The  muscular  coat  is  affected  to  a  greater  or  less  extent  and  shows 
degeneration  of  the  muscular  elements.  .  The  mucosa  may  be  normal 
in  appearance.  In  other  cases  it  may  be  acutely  inflamed,  and  on  its 
surface  there  may  be  hemorrhagic  areas  or  necrotic  ulceration.  In  a 
few  of  the  cases  the  mucous  membrane  has  been  pitted  by  small 
apertures  through  which  pus  may  be  seen  to  exude. 

Perigastritis  almost  regularly  accompanies  the  disease,  and  a  fibrino- 
purulent  peritonitis  occurs  in  over  half  the  cases.  Purulent  pleurisy 
or  pericarditis  and  abscess  of  the  liver  have  been  observed. 

The  duodenum  is  rarely  affected.  Involvement  of  the  esophagus 
may  occur,  either  secondary  to  the  gastric  infection  or,  as  in  the  case 
reported  by  Pfister,^  the  esophagus  may  be  the  seat  of  the  primary 
infection  to  which  the  gastric  phlegmon  is  secondary, 

'  Deutsch.  Archiv  f.  kliu.  Med.,  1906,  Ixxxvii,  499. 


34  ACUTE  GASTRITIS 

Circumscribed  Form. — The  pathology  of  the  circumscribed  form  is 
practically  that  of  a  localized  abscess  in  the  siibmiicosa.  The  abscess 
may  be  single  or  multiple,  and  may  vary  in  size  from  that  of  a  hazel- 
nut to  that  of  the  fist.  Such  an  abscess  is  almost  regularly  accom- 
panied by  perigastritis,  and  is  usually  accomi)anied  sooner  or  later  by 
the  lesions  of  diffuse  peritonitis.  Perforation  may  occur,  either  into 
the  stomach,  or  peritoneal  cavity  or  if  limiting  adhesions  are  formed, 
the  pus  may  burrow  into  any  near  region.  In  one  case  rupture  into  the 
lung  was  recorded. 

Symptoms. —  Diffuse  Form. — The  symptoms  of  the  acute  diffuse 
form  are  those  of  a  severe  acute  gastritis,  running  a  rapid  and  fatal 
course,  accompanied  by  signs  of  general  sepsis,  and  frequently  by  general 
peritonitis. 

The  onset  is  usually  abrupt,  ushered  in  by  a  burning  or  gnawing 
pain  in  the  pit  of  the  stomach,  and  vomiting.  A  chill  followed  by  a 
rise  in  temperature  may  be  noted  at  the  onset. 

Vomiting  is  one  of  the  most  constant  and  distressing  symptoms, 
appearing  early  and  lasting  throughout  the  disease.  The  vomited 
matters  consist  of  ingested  food,  mucus,  and  bile.  Pus  that  can  be 
recognized  as  such  by  the  naked  eye  is  rarely  found  in  the  vomited 
matters,  but  pus  to  a  microscopical  degree  is  often  present. 

Boas  and  Adams  both  deny  that  pus  is  ever  present  in  the  vomit 
of  the  true  phlegmonous  gastritis,  even  when  postmortem  examina- 
tion has  revealed  a  sieve-like  condition  of  the  mucous  membrane. 
The  writer  has,  however,  seen  a  case  in  which  pus  was  evident  to  the 
naked  eye. 

Pain  is  an  early  symptom  and  is  usually  violent  and  continuous, 
although  cases  have  been  reported  in  which  pain  has  been  either  slight 
or  absent. 

Tenderness  may  be  present  over  the  whole  abdomen,  but  is  more 
often  confined  to  the  epigastrium,  although,  as  a  rule,  pressure  over  the 
epigastrium  is  not  followed  l)y  an  increase  of  the  original  pain,  nor  is 
the  pain  apt  to  be  increased  by  moving  or  standing. 

Fever  is  usually  not  high,  ordinarily  ranging  between  99°  and  102°. 
Ill  rarer  cases  it  may  be  as  high  as  in  other  forms  of  sepsis,  and  may 
show  a  very  considerable  range  of  variation.  The  pulse  is  usually 
rai)id  and  feeble,  and  is  often  out  of  all  pr()])()rtion  to  the  degree  of  fever. 

Prostration  is  a  prominent  symptom  from  the  start,  merging  into 
collai)se  as  a  terminal  event. 

Mental  ])henoni(Mia  are  usually  exhibited  and  consist  of  restlessness 
interrupted  by  ])eriods  of  active  dcHriuiii,  which  cease  only  when  ter- 
minal coma  intervenes.  In  rarer  cases  the  mental  faculties  have  been 
maintained  until  within  a  few  moments  of  death. 


PHLEGMONOU,S  GASTIUTIH  35 

Jaundice  was  present  in  9  out  of  41  cases  reported  by  Leith. 

When  the  peritoneum  is  involved  the  abdomen  becomes  tympanitic 
and  diffusely  tender.  Prostration  becomes  more  marked,  and  the 
pulse  more  rapid  and  feeble.  The  vomiting  changes  its  character  to 
that  of  a  small  intestine  type,  characteristic  of  peritoneal  inflammation. 

There  are  cases  of  diffuse  phlegmonous  gastritis  that  run  a  course 
exceptional  in  this,  that  the  local  symptoms  are  masked  by  those  of 
the  general  infection.  Fever  of  a  pyemic  type,  with  chills  and  occasional 
vomiting,  may  be  the  only  symptoms  present. 

In  the  cases  that  complicate  infectious  disease  of  a  septic  character, 
the  symptoms  may  be  obscured  by  those  of  the  original  disease. 

Circumscribed  Form. — The  symptoms  of  the  circumscribed  form  are 
the  same  in  type  as  those  of  the  diffuse,  although  usually  less  severe 
and  more  protracted.  Epigastric  pain  and  vomiting  appear  suddenly, 
and  are  usually  continuous  throughout  the  disease,  although  they  may 
become  less  marked  as  the  disease  progresses. 

The  fever  assumes  a  hectic  or  pyemic  type,  and  is  usually  higher 
than  in  the  diffuse  form.  Drainage  of  the  abscess  into  the  cavity  of 
the  stomach  is  regularly  followed  by  a  reduction  in  the  fever,  as  long 
as  free  drainage  is  established.  In  a  few  cases  the  fever  may  be  slight 
or  even  absent,  as  in  the  case  reported  by  Asverus. 

Tenderness  is  present  in  the  epigastrium,  although  it  is  less  marked 
than  one  would  expect.  Rigidity  of  the  muscles  of  the  upper  part  of 
the  abdominal  wall  is  usually  present. 

Large  circumscribed  abscesses  may  rupture  into  the  peritoneal 
cavity,  causing  speedy  death,  or  rupture  may  occur  through  the  mucosa 
into  the  stomach.  In  the  latter  case  the  vomiting  of  blood-stained 
pus  may  be  followed  by  temporary  improvement  in  all  the  symptoms. 

In  a  case  reported  by  Callow,  twenty  ounces  of  pus  were  vomited  at 
one  time,  over  and  above  the  quantity  that  was  passed  in  the  stools. 
At  the  autopsy  a  quantity  of  pus  estimated  at  seven  pints  was  found 
in  the  peritoneal  cavity.  The  disease  had  developed  painlessly  and 
without  symptoms. 

It  is  very  difficult  to  determine  when  pus  is  vomited  whether  we 
are  dealing  with  a  localized  phlegmon  of  the  gastric  wall  or  with  a 
perigastric  abscess  that  has  ruptured  into  the  stomach. 

The  clinical  course  of  the  circumscribed  form  may  be  protracted  for 
weeks,  with  pain,  vomiting,  and  signs  of  general  sepsis. 

Diagnosis. — Diagnosis  is  exceedingly  difficult  during  life.  No  one  has 
ever  claimed  to  have  made  a  correct  diagnosis  of  the  diffuse  form. 

In  rare  instances  the  circumscribed  form  has  been  recognized  and 
successfully  treated.  The  points  on  which  the  diagnosis  is  based  are: 
An  acute  intense  gastritis,  local  pain  and  tenderness,  occasionally  with 


36  ACUTE  GASTRITIS 

muscular  rigidity  over  the  epigastrium,  or  a  palpable  tumor,  and  a 
polynucleosis.    Leukocytosis  of  30,400  was  found  by  Lengemann. 

The  differential  diagnosis  between  localized  gastric  phlegmon  and 
a  localized  peritoneal  abscess  following  perforation  of  the  stomach  wall 
by  ulcer  or  cancer  is  practically  impossible. 

Abscess  of  the  liver  may  run  a  course  almost  identical  in  its  symptom- 
complex.  Acute  pancreatitis  should  be  considered  a  possibility  in 
every  case. 

V.  l/cube  reports  a  case  in  which  all  the  symptoms  of  acute  purulent 
gastritis  were  present,  even  pus  in  the  vomited  matters,  but  the  autopsy 
showed  a  simple  gastritis  with  a  purulent  secretion  on  the  surface  of 
the  gastric  mucosa. 

Duration. — The  course  of  the  disease  is  rapid  in  the  diffuse  form,  in 
which  death  often  ensues  at  the  end  of  twenty-four  to  thirty-six  hours 
after  the  onset.  More  rarely  the  fatal  issue  may  be  delayed  three  or 
four  days. 

In  the  circumscribed  form  the  duration  is  somewhat  longer,  often 
extending  over  ten  days  or  two  weeks,  in  rarer  cases,  longer  than 
this. 

Prognosis. — The  prognosis  is  extremely  grave,  the  mortality  rate 
being  about  98  per  cent. 

Deninger^  reports  the  case  of  a  female,  aged  thirty-two  years,  who 
complained  of  fever,  violent  epigastric  pain,  and  tenderness,  with 
diarrhea.  A  tumor  as  large  as  the  fist  was  distinctly  to  be  felt.  On 
the  nineteenth  day  she  vomited  a  large  quantity  of  pus,  followed  by 
a  disappearance  of  the  tumor,  and  recovery. 

Glax^  records  the  case  of  a  young  man,  aged  seventeen  years,  who 
suffered  from  severe  pain  in  the  stomach,  and  the  vomiting  of  large 
quantities  of  pus,  with  gradual  diminution  of  his  symptoms.  Kecovery 
occurred  in  four  weeks. 

Mikulicz  and  Bovee^  have  reported  recovery  after  surgical  ex{)lora- 
tion  and  the  drainage  of  the  cavity.  All  the  cases  of  recovery  to  be 
noticed  are  those  of  the  circumscribed  form. 

Treatment.^ — Aside  from  those  very  rare  cases  in  which  spontaneous 
recovery  has  apparently  occurred,  there  is  very  little  hope  indeed, 
even  by  surgery,  in  effecting  a  cure  in  the  diffuse  form,  and  this 
difficulty  is  increased  by  the  fact  that  in  no  reported  case  was  the 
diagnosis  clearly  made  before  death. 

In  the  circumscribed  form,  however,  surgical  intervention  may  be 
resorted  to,  and  the  abscess  drained.    Had  the  diagnosis  of  a  localized 

1  Doutsch.  Arch.  f.  klin.  Med.,  1879,  xxxvi,  624. 

2  Berlin,  klin.  Woch.,  1879,  xvi,  No.  38,  p.  565. 

'  Amoriciin  .Jounuil  of  the  Medical  Sciences,  1008,  cxxxv,  662. 


TOXIC  GASTRITIS  37 

abscess,  in  or  about  the  stomach,  been  made,  and  if  exploration  and 
drainage  had  been  resorted  to,  it  is  probable  that  the  death  rate  would 
have  been  less  appalling  than  it  now  is. 


TOXIC    GASTRITIS 

The  name  toxic  gastritis  indicates  a  variety  of  lesions  of  the  stomach 
produced  by  the  taking  of  poisonous  doses  of  chemical  irritants. 

Etiology. — The  number  of  irritant  poisons  that  may  give  rise  to 
the  condition  is  numerous.    Among  the  most  important  are: 

1.  The  concentrated  acids,  principally  nitric,  sulphuric,  hydrochloric, 
hydrocyanic,  carbolic,  and  oxalic  acid. 

2.  Concentrated  alkalies,  such  as  lye  and  ammonia. 

3.  Irritant  metallic  salts,  especially  those  of  arsenic,  copper,  silver, 
and  mercury. 

4.  The  essential  oils,  such  as  turpentine,  oil  of  Copaiba. 

5.  Certain  metallic  elements,  such  as  iodine,  bromine,  and  phos- 
phorus, the  latter  being  often  an  ingredient  in  rat  poisons  that  are 
taken  with  suicidal  intent. 

Pathology. — The  intensity  of  the  damage  done  depends  upon  the 
character,  the  concentration,  and  quantity  of  the  poison,  the  condition 
of  fulness  or  emptiness  of  the  stomach  at  the  time  the  poison  is  taken, 
and  the  length  of  time  the  irritant  remains  in  the  stomach  before  it  is 
ejected,  washed  out,  or  neutralized  by  the  appropriate  chemical  anti- 
dote. Accordingly,  we  find  lesions  varying  from  simple  hyperemia  to 
ulceration,  gangrene,  or  perforation. 

In  the  mildest  form  there  occurs  a  congestion  of  the  mucous 
membrane,  either  diffuse  or  in  localized  areas,  often  with  croupous 
exudations  in  patches,  especially  on  the  rugae.  There  is  usually  a 
well-marked  serous  effusion  into  the  submucous  coat.  Punctate 
hemorrhages  into  the  substance  of  the  mucosa  may  occur. 

If  the  damage  be  more  intense,  areas  of  sloughing  are  seen  surrounded 
by  zones  of  intense  congestion.  In  the  case  of  even  more  concentrated 
and  destructive  poisons  the  mucous  and  even  the  outer  coats  may  be 
converted  into  a  pulpy  mass  of  necrotic  tissue,  occasionally  extending 
through  the  wall  of  the  stomach  so  that  perforation  may  ensue. 

The  appearance  of  the  slough  differs  in  different  poisons.  Sulphuric 
acid  may  produce  grayish  or  grayish-white  sloughs,  later  becoming 
dark  brown  as  though  charred.  In  less  intense  poisoning  the  parts 
may  appear  as  if  coated  with  white  paint.  Perforation  is  perhaps  more 
common  with  sulphuric  acid  poisoning  than  with  any  other  form  of 
irritant,  occurring  in  about  one-third  of  the  cases. 


38  ACUTE  GASTRITIS 

Pure  carl)()lic  acid  is  a  good  fixative  for  body  tissues,  and  it  may 
happen  that  should  death  occur  soon  after  the  ingestion  of  this  poison. 
the  stomach  may  look  as  if  it  had  been  boiled.  The  acid  even  may 
leak  through  the  wall  of  the  stomach  and  act  caustically  upon  the 
peritoneimi  and  even  upon  the  spleen,  and  yet  microscopical  examina- 
tion may  show  that  the  structures  of  the  stomach  are  normal  in  appear- 
ance and  well  preserved.  If  the  caustic  action  is  less  deep,  the  mucous 
membrane  may  preserve  normal  histological  appearance,  but  underneath 
is  a  layer  of  dead  or  necrotic  tissue. 

Nitric  acid  usually  produces  sloughs  of  a  yellowish  color,  resem- 
bling wet  chamois  leather.  This  acid  is  somewhat  less  corrosive  than 
sulphuric  acid.  No  case  of  perforation  w'ith  poison  by  hydrochloric 
acid  has  been  put  on  record. 

Carbolic  acid  usually  produces  a  whitening  of  the  mucous  membrane 
in  patches,  having  a  sodden  appearance.  Later  the  affected  areas  may 
appear  dryish,  as  if  tanned.  The  characteristic  of  hydrocyanic  poison- 
ing is  the  bright  scarlet-red  appearance  of  the  slough.  Alkalies  are,  as 
a  rule,  more  destructive  than  are  the  acids,  and  the  sloughs  are  softer, 
more  gelatinous,  and  more  widely  spread. 

The  poisons  act  chiefly  on  those  portions  of  the  stomach  and  upper 
passages  with  which  they  first  come  in  contact.  The  parts  most  affected 
are  the  lips  and  mouth,  pharynx,  the  first  portion  and  the  lower  portion 
of  the  esophagus,  the  pyloric  end  of  the  stomach,  and  pyloric  antrum. 
The  greater  part  of  the  esophagus  usually  escapes  serious  damage, 
although  patches  of  ulceration,  or  even  of  gangrene,  may  be  seen. 
While  a  general  cauterization  of  the  stomach  may  occur,  the  lesions 
are  usually  most  marked  in  the  pyloric  portion. 

As  a  rule,  the  entrance  of  the  irritant  into  the  stomach  causes  a 
sudden  cessation  of  peristaltic  action,  so  that  cauterization  does  not 
usually  extend  below  the  stomach.  In  more  rare  cases,  however,  the 
poison  obtains  entrance  in  the  duoderumi  or  even  the  upper  ileum,  and 
produces  lesions  similar  to  those  in  the  stomach,  although  somewhat 
less  intense. 

Should  the  patient  survive  the  acute  effects  of  the  poisoning,  the 
corrosive  process  is  followed  by  the  formation  of  granular  tissue  which 
results  in  cicatrization.  If  the  affected  areas  be  small,  the  defects  may 
not  be  of  serious  import.  When,  however,  the  damage  is  extensive,  the 
scar  tissue  may  contract  and  lead  to  deformities  such  as  hour-glass 
deformity,  sacculations  of  the  stomach,  and  pyloric  stenosis.  In  other 
cases  the  mucous  membrane  of  the  stomach  is  replaced  by  thick  fibrous 
tissue,  which  j)crmeates  the  deeper  coats,  so  that  the  stomach  is  shrunken 
and  contracted,  its  lumen  diminished,  and  its  walls  practically  con- 
verted into  dense  scar  tissue. 


TOXIC  GASTRITIS  39 

In  the  esophagus  there  are  apt  to  be  developed  strictures,  varying  in 
extent  and  tightness,  or  the  esophagus  may  become  densely  adherent 
to  surrounding  structures,  especially  the  vertebral  column,  from  which 
it  cannot  be  stripped  without  tearing.  Similar  adhesions  may  bind  the 
stomach  to  adjacent  organs. 

Symptoms. — The  symptoms  vary  naturally  with  the  intensity  of  the 
corrosive  poison.  In  the  most  severe  forms,  such  as  follow  attempts 
at  suicide  by  concentrated  acids,  the  taking  of  the  poison  produces  a 
scalding  pain  in  the  mouth  and  the  throat,  and  intense  burning  pain 
in  the  epigastrium.  The  agony  may  be  well-nigh  unendurable,  and 
may  induce  a  condition  akin  to  surgical  shock.  The  face  is  anxious, 
the  pulse  small  and  feeble,  respiration  rapid  and  shallow,  the  lips  and 
face  become  cyanotic,  and  the  patient  may  die  of  collapse  with  or 
without  general  convulsions,  A  fatal  issue  may  occur  within  a  few 
hours  in  extreme  cases. 

In  instances  of  severe  shock,  such  as  accompany  extensive  corrosion, 
pain  may  be  absent  until  a  certain  degree  of  reaction  takes  place. 
Vomiting  may  not  occur  until  after  the  first  symptoms  of  shock  have 
passed. 

Should  the  patient  survive  the  initial  symptoms  of  shock,  the  agoni- 
zing symptoms  continue  without  abatement.  Deglutition  is  excessively 
painful,  often  impossible  by  reason  of  pain  and  interference  with  the 
motor  power  of  the  esophagus.  The  soreness  of  the  mouth  and  throat 
may  be  terrific,  especially  when  the  sloughs  separate  and  leave  bleeding 
ulcerations.  Thirst  is  excessive  and  cannot  be  assuaged.  Vomiting 
sets  in  after  the  acute  stage  of  shock  is  passed,  is  incessant,  extremely 
painful,  and  brings  no  relief  to  the  distress.  The  vomiting  is  usually 
associated  with  continued  retching.  The  vomited  matters  contain 
blood,  mucus,  and  traces  of  the  poison,  thus  facilitating  the  diagnosis 
in  cases  where  the  previous  history  is  unobtainable.  Shreds  of  mucous 
membrane  and  fragments  of  necrotic  tissue  may  also  be  found. 

The  epigastrium  is  usually  excessively  tender  to  pressure.  There 
may  be  fever,  often  obtaining  the  height  of  104°.  The  urine  is  usually 
diminished,  and  contains  albumin  casts,  and  often  blood  cells,  from  an 
acute  toxic  nephritis  induced  by  the  poison.  Total  suppression  may 
occur.  After  some  days,  usually  between  the  seventh  and  the  tenth, 
there  may  be  vomited  casts  of  the  stomach  or  esophagus.  Hemorrhage, 
often  profuse,  may  occur  at  this  time  from  erosion  of  one  of  the  gastric 
arteries.  Diarrhea  with  thin,  bloody  passages  may  occur,  and  symptoms 
of  an  acute  ulcerative  colitis  may  be  added,  especially  after  poisoning 
by  corrosive  sublimate. 

In  the  case  of  certain  drug  poisons,  such  as  phosphorus,  symptoms 
of  acute  degeneration  of  the  liver  occur,  continued  nausea,  intense 


40  ACUTE  GASTRITIS 

jaundice, and  tendency  toward  hemorrhage.  In  such  cases  the  symptoms 
of  toxic  nephritis  are  usually  well-marked.  Should  extensive  gangrene 
or  deep  destruction  of  the  stomach  wall  occur  the  pain  may  become 
more  generalized,  tympanites  and  other  signs  of  peritonitis  supervene, 
and  the  patient  dies  within  three  or  four  days  from  perforation  of  the 
stomach. 

If  the  effect  of  the  poison  be  not  great  enough  to  cause  immediate 
death  of  the  patient,  the  symptoms  may  gradually  amend  in  a  few 
days,  but  improvement  is  slow  and  often  incomplete.  The  patient  may 
continue  for  days  or  weeks,  with  slight  fever,  pain,  and  vomiting, 
becoming  more  and  more  emaciated.  From  this  condition  he  may 
gradually  improve,  or  death  may  result  from  inanition  and  weakness. 

Recovery  may  be  incomplete  because  of  extensive  cicatrices  that 
follow  the  healing  of  the  ulcerated  areas.  There  may  be  cicatricial 
stenosis  of  the  esophagus,  usually  at  the  upper  end,  more  rarely  in  the 
lower  third  or  throughout  its  length.  Pyloric  stenosis  may  ensue.  In 
some  instances  of  excessive  involvement  of  the  stomach,  the  patient 
lingers  for  weeks  with  nausea,  vomiting,  and  epigastric  pain,  and  dies 
exhausted.  In  these  cases  the  stomach  is  apt  to  be  shrunken,  and  its 
walls  thickened  by  the  growth  of  dense  fibrous  tissue,  which  shows  on 
its  surface  only  here  and  there,  traces  of  mucous  membrane. 

Diagnosis.^ — Diagnosis  is  readily  made.  The  fact  that  poison  has 
been  taken  may  be  elicited  from  the  patient,  or  from  friends,  or  some 
witness  of  the  act.  Search  should  be  made  for  bottles  containing  the 
remains  of  the  poisonous  dose.  Evidence  of  corrosive  poison  are 
usually  visible  on  the  lips,  or  in  the  mouth  and  ])harynx,  or  upon  the 
clothes  of  the  patient.  Further  evidence  may  be  afforded  by  the  odor 
of  the  breath  or  the  appearance  and  reaction  of  the  vomited  matters. 

Prognosis. — The  prognosis  is  always  grave  in  the  severer  types  of 
poisoning,  and  expression  of  o])inion  should  in  every  case  be  given 
guardedly.  Recovery  is  usually  tedious  and  often  incomplete.  The 
flanger  of  the  resulting  stenoses  should  always  be  l)orne  in  mind. 

Treatment. — The  first  indication  of  the  treatment  is  naturally  to 
neutralize  the  i)()ison  that  has  l)een  taken.  This  is  preferable  to  earl}' 
emesis  if  the  i)r()por  antidote  is  at  hand.  Otherwise  to  avoid  delay, 
the  stomach  should  be  rapidly  emptied,  by  giving  the  patient  large 
draughts  of  water  or  demulcent  drinks,  and  by  tickling  the  throat. 
This  i)rocedure  is  preferable  to  giving  aponiorphine. 

For  consideration  of  the  proper  antidotes  the  reader  is  referred  to 
books  on  toxicology. 

The  use  of  the  stomach  tube  as  a  means  of  eTii])tying  the  stomach  is 
said  to  be  contraindicated,  owing  to  the  danger  of  perforation.  That 
this  danger  does  undoubtedly  exist  cannot  be  denied,  l)ut  the  risk  run. 


TOXIC  GASTRITIS  41 

seems  to  the  writer,  to  be  less  by  the  use  of  the  tube  than  by  allowing 
the  poison  to  remain  in  the  stomach  even  though  proper  antidotes  have 
been  administered,  or  by  straining  the  stomach  by  repeated  efforts 
at  vomiting.  Lavage  naturally  removes  the  poison  more  thoroughly 
than  is  possible  by  simple  vomiting,  and  has  the  further  advantage  that 
the  lavage  water  can  be  medicated  by  the  addition  of  the  chemical 
antidote.  The  removal  of  the  poison  by  the  tube,  furthermore,  mini- 
mizes the  corrosive  effect  on  the  esophagus  by  a  second  transit  through 
it  of  a  corroding  poison.  For  these  reasons  the  writer  believes  it  is 
much  better  to  run  the  risk  of  perforation,  and  to  wash  the  stomach 
gently  but  thoroughly. 

After  the  stomach  has  been  emptied,  further  attempts  at  vomiting 
should  be  controlled  by  opiates  or  anodyne,  preferably  administered 
hypodermically.  Collapse  and  shock  are  to  be  combated  on  the  usual 
principles.  Hot  fomentations  over  the  epigastrium  are  of  service  in 
mitigating  the  epigastric  pain,  and  demulcent  drinks,  with  or  without 
the  addition  of  bismuth  subnitrate  and  orthoform,  may  be  given, 
unless  contraindicated  by  attempts  at  vomiting.  Feeding  the  patient 
by  the  stomach  is  to  be  interdicted  until  the  distressing  symptoms 
subside,  and  until  then  rectal  alimentation  should  be  resorted  to. 
Should  diarrhea  prevent  the  latter  form  of  feeding,  and  should  inani- 
tion threaten,  duodenal  alimentation  may  be  advised,  by  the  use  of 
Einhorn's  apparatus. 


CHAPTER   II 
CHRONIC  GASTRITIS 

Before  the  general  adoption  of  gastric  analyses  the  diagnosis  of 
"chronic  gastritis"  was  made  indiscriminately  in  cases  of  continued 
dyspepsia  characterized  by  nausea  and  vomiting,  that  could  not  be 
ascribed  to  ulcer  or  cancer,  so  that  the  disease  was  regarded  as  one  of 
common  occurrence.  During  late  years  refinements  of  diagnosis  have 
shown  that  the  disease  is  relatively  more  rare  than  was  supposed.  Of 
the  writer's  private  patients  suffering  from  digestive  disorders,  less 
than  8  per  cent,  were  sufferers  from  this  ailment,  although  its  frequency 
cannot  be  ascertained  with  any  exactness,  owing  to  the  large  number 
of  cases  in  which  the  disease  runs  a  latent  course. 

Primary  gastritis  is  much  less  common  than  the  secondary  form. 
In  130G  autopsies  at  the  Royal  Victoria  Hospital,  gastritis  was  encoun- 
tered in  108,  of  which  only  16  were  not  definitely  secondary  to  other 
causes. 

Pathological  reports  are  frequently  of  little  value,  as  microscopic 
examinations  are  not  usually  made,  so  that  antemortem  congestion, 
contraction  of  the  viscus  causing  apparent  thickening  of  its  wall, 
polypoid  excrescences  and  mammillated  appearances  of  its  surface  that 
show  microscopically  no  true  inflammatory  changes,  have  been  roughly 
designated  as  gastric  catarrhs. 

Postmortem  changes  occur  with  surprising  rapidity  so  that  the 
appearance  of  the  mucosa  is  quite  different  from  that  during  life.  It 
is  often  extremely  difficult  at  the  autopsy  to  say  whether  or  not  a 
gastritis  is  present. 

Etiology. — Primary  and  secondary  gastritis  are  recognized.  The 
causes  for  the  primary  form  embrace  all  forms  of  irritation  of  the 
stomach  that  are  continued  over  a  long  period.  The  dietetic  errors 
that  may  so  result  are  legion.  Food  that  is  improperly  cooked,  unwhole- 
.some,  and  irritating  in  (juality  or  excessive  in  quantity,  is  a  prolific 
cause.  ^Vlany  cases  follow  rapid  eating  and  insufficient  mastication, 
or  eating  at  irregular  hours.  Excesses  in  tea,  coffee,  and  in  the  chewing 
of  tobacco  may  be  mentioned  as  frequent  causes,  especially  among 
the  lower  classes. 

Among  other  etiological  factors  may  be  mentioned  the  taking  of 
irritating  drugs  and   the  abuse  of  i)urgatives.     The  drinking  of  large 


ETIOLOGY  -  43 

quantities  of  iced  water  is  a  common  cause.  It  is  generally  considered 
that  smoking  to  excess  ma\'  produce  the  disease,  but  the  writer  can 
find  no  clinical  evidence  to  support  this  statement,  although  it  seems 
evident  that  abuse  of  tobacco  may  result  in  many  forms  of  neurotic 
indigestion  or  even  in  atony. 

Overindulgence  in  alcohol  is  by  far  the  commonest  cause  for  gastric 
catarrh,  especially  the  use  of  the  more  concentrated  forms  of  alcoholic 
beverages,  and- may  lead  to  the  definite  clinical  type  commonly  spoken 
of  as  alcoholic  gastritis.  Excessive  alcoholic  habits  are,  however,  by 
no  means  followed  with  any  certainty  by  gastritis,  nor  is  the  intensity 
of  the  inflammatory  process,  if  it  should  occur,  proportionate  to  the 
degree  of  the  alcoholic  abuse.  Some  stomachs  seem  immune  to  alcoholic 
irritation,  while  others  are  excessively  susceptible,  and  react  to  quantities 
of  alcohol  that  may  seem  to  be  within  the  limits  of  ordinary  temperance. 
Definite  lesions  of  gastritis  were  found  in  but  one-half  of  40  cases  of 
alcoholism  autopsied  at  the  Royal  Victoria  Hospital.  In  the  case  of 
an  alcoholic  tramp  who  was  repeatedly  treated  at  Bellevue  Hospital 
for  delirium  tremens,  and  who  died  from  wet-brain  and  pneumonia, 
the  stomach  was  filled  with  formaline  solution  a  few  minutes  after 
death,  and  examined  microscopically.  It  was  found  to  be  so  free  from 
all  evidence  of  disease  that  it  could  be  demonstrated  to  a  class  in  normal 
histology  as  an  absolutely  normal  stomach. 

Acute  gastritis  does  not  usually  merge  into  the  chronic  form,  except 
when  recurrences  occur  at  short  intervals  from  repeated  dietetic  errors, 
so  that  the  inflammation  has  not  the  chance  to  subside  between  the 
attacks. 

Although  in  many  of  the  patients,  one  of  the  above  definite  causes 
can  be  ascribed,  gastritis  is  often  encountered  in  those  who  have  led 
blameless  lives,  and  whose  diet  and  mode  of  life  have  been  simple  and 
wholesome,  and  we  are  at  a  loss  to  account  for  its  occurrence.  The 
relation  of  the  milder  forms  of  bacterial  infection  to  these  unexplained 
cases  of  gastric  catarrh,  has  never  been  satisfactorily  investigated, 
although  the  occurrence  of  ulcers  experimentally  produced  in  dogs  by 
feeding  them  wdth  cultures  of  the  Bacillus  coli,  and  similar  lesions 
following  the  use  of  various  toxins,  suggest  that  a  chronic  catarrh  may 
result  from  mild  bacterial  poisoning,  insufficient  to  produce  actual 
ulceration. 

Secondary  catarrh  of  the  stomach  occurs  either  as  a  complication  of 
any  gastric  disease  of  a  chronic  character,  such  as  ulcer,  cancer,  or 
pyloric  stenosis,  or  it  may  be  an  associated  lesion  of  chronic  diseases  of 
the  heart,  arteries,  kidneys,  or  it  may  be  concomitant  with  chronic 
pulmonary  disorders. 

The  atrophic  form  may  accompany  cancer  even  if  this  invade  a 


44 


CHRONIC  GASTRITIS 


distant  organ,  and  often  results  from  pernicious  anemia.  The  writer 
believes  that  atrophy  of  the  gastric  tubules  is  rather  the  result  of  than 
the  cause  for  this  latter  disease. 

Senile  changes  of  an  atrophic  character,  especially  marked  in  the 
prepyloric  portion,  are  not  uncommonly  found  in  those  aged  over  fifty 
years,  and  are  one  of  the  causes  for  indigestion  in  aged  patients. 

Pathology. — Chronic  inflammation  of  the  stomach  produces  a  some- 
what varied  pathological  picture  and  to  the  different  appearances 
presented,  various  descripti\'e  names  have  been  applied.  In  general, 
two  distinct  types  are  seen;  the  one  productive  with  an  increase  of 
connective  tissue  and  more  or  less  thickening  of  the  stomach  wall; 
the  other,  atrophic,  with  atrophy  of  the  mucous  membrane  as  the 
essential  change.  As  in  other  inflammatory  conditions  of  the  stomach, 
the  pyloric  region  is  most  apt  to  be  involved,  and  in  some  cases  the 
changes  are  confined  to  this  location. 


Fig.  4 


r    nTTf|iiir|iTTT]TrfiTmTjTtiiTfTfi|rnmrnpTirjrrn 
I  ol-M    )        2         3         4'         5! 

L  Jililil.hUiiliJilaUkliUlUiLl 


Chronic  productive  gastritis  showing  miiniinillat' il  imirous  membrane. 


Chronic  Productive  Type. — The  mucous  membrane  is  indurated  and 
gray,  grayish  red,  or  grayish  violet  in  color.  In  many  cases,  especially 
those  of  long  standing,  there  is  a  diffuse  or  patchy  slate  color  from 
changes  in   the  blood   jjjgmcnt.     The  mucous  membrane  tears  less 


PATHOLOGY 


45 


readily  than  normal,  aiul  it  is  not  normally  movable  upon  the  under- 
lying tissue.    Occosionally  small  ulcers  or  superficial  erosions  are  seen. 

At  times  the  thickened  mucosa  appears  rough,  wrinkled,  and  mamil- 
lated.  It  is  to  this  condition  that  the  French  have  given  the  name 
"etat  mammeolone."  Rarely  this  change  is  so  aggravated  that  the 
term  "gastritis  polyposis"  is  fitting.  These  protuberances  cannot  be 
smoothed  out  by  stretching  as  can  the  contractions  of  the  normal 
stomach. 

This  type  of  gastritis  may  go  on  to  a  typical  cirrhosis  ventriculi, 
with  vjery  great  thickening  of  the  stomach  wall,  and  a  marked  reduc- 
tion in  the  size  of  the  organ. 

Microscopically,  there  is  seen  a  proliferation  of  the  interstitial  and 
interglandular  connective  tissue,  and  of  the  glands  themselves. 


Fig.  5 


B 


Chronic  atrophic  gastritis.     A,  mucosa,  showing  marked  increase  in  fibrous  tissue  with  atrophy 
of  the  glands;  B,  submucosa;  C,  muscularis. 


The  thickened  submucosa  is  firmly  adherent  to  the  muscularis  which 
is  generally  very  considerably  thickened,  the  hypertrophy  affecting 
principally  the  circular  coat.  This  thickening  may  be  so  marked  at 
the  pylorus  as  to  cause  a  certain  amount  of  stenosis  with  subsequent 
dilatation  of  the  stomach. 

Even  the  serosa  may  be  thickened  and  wrinkled. 

The  gland  tubules  in  the  mucosa  may  show  irregular  branching  and 


46  CHRONIC  GASTRITIS 

cyst  formation.  The  latter  may  be  so  marked  as  to  cause  a  true 
"gastritis  cystica." 

At  times  there  may  be  seen  in  the  midst  of  the  mucous  membrane, 
patches  of  epitheHum  and  glands,  identical  with  the  intestinal  type. 

Atrophic  Type. — The  chief  characteristic  of  this  form  of  chronic 
gastritis,  which  is  also  known  by  the  names  "  anadenia  ventriculi"  and 
"phthisis  ventriculi,"  is  atrophy  of  the  mucous  membrane  with  con- 
sequent destruction  of  the  gastric  glands.  There  is  often  an  associated 
thinning  of  the  other  coats  of  the  stomach  with  dilatation.  However, 
as  the  condition  is  quite  commonly  secondary  to  the  productive  form, 
the  mucosa  may  become  extremely  atrophic  while  the  rest  of  the 
stomach  wall  remains  very  much  thickened. 

The  mucosa  is  pale,  opaque,  and  smooth,  and  the  atrophy  may  be 
so  extreme  that  scarcely  a  trace  of  glandular  epithelium  survives. 

This  atrophic  gastritis  is  sometimes  well  seen  in  pernicious  anemias 
as  in  the  case  described  by  Osier  and  Henry,  in  which  the  lining  mem- 
brane of  the  stomach  was  "  converted  into  a  perfectly  smooth,  cuticular 
structure,  showing  no  trace  w^hatever  of  glandular  elements. 

Types. — Two  forms  of  chronic  gastritis  are  to  be  described: 

1.  Catarrhal  gastritis,  suhdivided  into: 

(a)  Those  cases  with  hyperacidity. 

(b)  Those  cases  with  normal  acidity. 

(c)  Those  cases  with  anacidity  or  "achylia." 

2.  Alcoholic  gastritis. 


CHRONIC    CATARRHAL    GASTRITIS 

Clinical  Types. — The  division  of  chronic  catarrhal  gastritis  into 
three  classes  depending  upon  the  amount  of  gastric  secretion  present 
is  not  from  any  pathological  reason,  but  simply  because  it  facilitates 
the  clinical  description  of  the  disease. 

Of  350  cases  of  gastritis  of  non-alcoholic  origin,  observed  by  the 
writer  in  private  practice,  40  per  cent,  showed  hyperacidity,  24.5  per 
cent,  showed  normal  or  reduced  acidity,  35.5  per  cent,  showed  anacidity 
or  achylia.  In  h(>sj)ital  i)racticc  the  ])roi)()rti()n  of  anacid  cases  was 
much  higher. 

These  figures  difli'er  from  those  of  McCaskey,  who  in  600  cases  of  gas- 
tritis found  hyperacidity  in  20  per  cent.,  normal  or  subnormal  acidity 
in  60  i)er  cent.,  anacidity  in  20  per  cent.  ]\IcCaskey,  however,  does 
not  distinguish  between  the  alcoholic  and  the  non-alcoholic  form  of 
gastritis  as  does  the  writer.  It  will  be  shown  later  that  in  the  alcoholic 
form,  hyperacidity  is  not  as  frequent,  and   that   normal  or  slightly 


CHRONIC  CATARRHAL  GASTRITIS  47 

reduced  acidity  is  much  more  frequent  than  in  the  non-alcoholic 
variety,  so  that  after  all  the  two  sets  of  figures  may  not  be  as  much 
dissimilar  as  they  may  at  first  appear. 

I.  Gastritis  with  Hyperacidity. — These  cases  are  frequently  alluded  to 
as  "acid  catarrh,"  or  "hyperpeptic  gastritis."  Clinically  hyperacid 
gastritis  presents  itself  in  one  of  three  different  clinical  types : 

(a)  Acidity  Type. — The  first  group  comprises  those  cases  whose  gastric 
symptoms  consist  of  heart-burn  and  acidity.  The  patients  are  apt  to 
be  well  nourished  and  of  good  appetite;  they  are  not  nauseated,  neither 
do  they  vomit  their  food.  Their  chief  complaint  is  that  of  heart-burn 
occurring  at  the  height  of  digestion,  one  or  two  hours  after  food,  for 
which  they  take  soda,  with  instant  relief.  This  feeling  of  acidity  rarely 
if  ever  gives  rise  to  a  definite  pain,  a  point  of  considerable  importance 
in  making  a  diagnosis  between  this  condition  and  ulcer,  the  disease  for 
which  acid  gastritis  is  most  liable  to  be  mistaken.  In  cases  of  ulcer 
without  marked  and  characteristic  pain,  a  difi^erential  diagnosis  may 
be  impossible,  although  the  presence  of  occult  blood  in  the  stools  may 
be  of  service  in  dispelling  our  doubts.  Persistent  intractable  "  hyperacid 
gastritis"  usually  turns  out,  however,  to  be  chronic  ulcer. 

Acid  catarrh  may  also  resemble  functional  hyperacidity,  especially 
as  the  symptoms  are  usually  aggravated  by  overwrought  and  nervous 
states,  and  by  stress  of  work,  and  are  almost  regularly  less  evident 
during  freedom  from  business  cares.  Long  continuance  of  the  symp- 
toms, absence  of  other  neurotic  manifestations,  and  the  presence  of 
mucus  with  evidences  of  imperfect  digestion  as  shown  by  the  gastric 
analysis  point  to  an  organic  cause  for  the  complaint.  As  an  example 
of  this  type  may  be  given  the  following  case: 

Male,  aged  forty  years.  For  eight  years  has  suffered  from  heart- 
burn, better  in  summer  when  he  rests  from  work  and  takes  daily  exer- 
cise, than  in  winter  when  he  leads  a  sedentary  and  harassing  life.  He 
is  never  without  soda  mints,  which  he  takes  almost  regularly  between 
meals.  His  appetite  is  good,  he  is  well  nourished  and  not  anemic,  and 
aside  from  his  acidity  has  no  other  gastric  symptoms  whatever.  He 
never  has  what  he  can  call  a  pain. 

Physical  Exmnination.  The  stomach  is  of  normal  size  and  of  good 
muscular  power.  Fasting  stomach  contains  25  to  30  c.c.  of  glairy 
mucus  without  vestige  of  food  remains.  Test  breakfast  shows  a  fine 
admixture  of  mucus  of  gastric  origin.    Total  acidity,  86;  free  HCl,  60. 

Lavage  brings  large  quantities  of  thick,  glairy  mucus  that  can  be 
lifted  by  a  hook.  By  lavage  and  diet  the  symptoms  disappeared  and 
for  a  number  of  years  he  has  remained  well.  Many  cases  of  ulcer 
resemble  this,  but  the  writer  believes  the  case  to  have  been  one  of 
gastritis  of  the  acid  type. 


48  CHRONIC  GASTRITIS 

(h)  Diarrhea  Type. — The  second  group  includes  those  cases  in  which 
diarrhea  is  the  prominent  symptom  and  in  which  gastric  distress  of 
any  kind  is  either  insignificant  or  absent  altogether.  The  evacuations 
are  usually  watery  and  profuse,  and  may  occur  with  special  frequence 
during  the  early  morning  hours.  Mucus  in  the  stools  is  rarely  present, 
nor  are  there  traces  of  occult  blood,  the  absence  of  any  evidences  of 
catarrh  pointing  to  an  increase  in  intestinal  peristalsis  as  a  cause  for 
the  diarrhea.  Carmine  or  charcoal,  given  by  mouth,  usually  appears 
in  the  stools  within  ten  to  fifteen  hours,  indicating  an  abnormal 
raj^idity  in  transit.  Undigested  particles  of  food,  chiefly  vegetable 
debris,  may  be  found  especially  if  mastication  be  not  thorough.  Undi- 
gested meat  fibers  are  but  rarely  seen. 

There  may  be  abdominal  distress  or  discomfort  two  to  four  hours 
after  meals,  often  accompanied  by  borborygmi  and  distention,  but 
actual  pain  either  before  or  following  the  action  of  the  bowels  is  quite 
uncommon. 

The  eating  of  hearty  food  usually  aggravates  the  diarrhea,  simple 
or  semisolid  food  regularly  reduces  its  severity.  The  ordinary  tfeat- 
ment  by  astringents  checks  the  disease  but  temporarily;  sooner  or 
later  outbreaks  occur.  Considerable  loss  of  flesh  and  strength  result 
from  the  continued  drain,  and  anemia  often  becomes  quite  pronounced. 
A  typical  case  is  as  follows: 

S.  A.,  aged  forty-three  years,  for  three  months  has  suffered  from 
diarrhea,  having  from  five  to  twelve  loose  stools  a  day,  without  blood 
or  mucus.  During  this  time  he  has  lost  twenty-seven  pounds  in  weight, 
has  grown  so  weak  and  anemic  that  he  was  referred  to  the  writer  as 
suffering  from  malignant  disease  of  the  colon.  The  diarrhea,  while 
checked  temporarily  by  drugs,  soon  returns  as  severely  as  before.  The 
appetite  is  good,  but  as  solid  food  regularly  aggravates  his  trouble, 
he  has  been  obliged  to  diet  himself  most  rigidly,  and  has  thereby  added 
to  the  loss  of  his  flesh  and  strength.  He  has  neither  pain,  nausea, 
vomiting,  nor  any  gastric  distress,  but  he  is  annoyed  by  abdominal 
distention  and  uneasiness  most  of  the  time. 

Examinati(jn  shows  a  normally  located  colon  of  good  muscular  tone, 
and  with(nit  any  trace  of  catarrh.  The  stools  are  of  thin  pea-soup 
consistency,  apparently  well  digested,  and  contain  neither  blood  nor 
mucus. 

The  fasting  stomach  contains  25  c.c.  of  glairy  mucus  without  free 
hydrochloric  acid.  Examination  of  the  test  breakfast  shows  a  mod- 
erate amount  of  imperfectly  chymifled  breadstuff'  mixed  witli  thick 
ropy  mucus  of  gastric  origin.  Total  acidity,  85.  Lavage  brings  large 
amounts  of  glairy  mucus. 

By  lavage,  diet,  and  small  doses  of  bromides  to  diminish  his  intestinal 


CHRONIC  CATARRHAL  GASTRiriS  49 

peristalsis,  the  diarrhea  ceased  in  three  days,  his  flesh  and  strength 
returned,  and  he  has  never  had  any  return  of  his  trouble. 

These  are  the  cases  often  treated  for  acute  or  chronic  colitis.  The 
rule  should  be,  in  every  case  of  diarrhea,  to  examine  the  stools  and  to 
wash  out  the  colon.  If  mucus  in  excess  be  not  found,  gastric  analysis 
should  at  once  be  made,  with  a  strong  probability  of  finding  the  cause 
for  the  whole  offending.  It  is  interesting  that  the  diarrhea  in  these 
cases  cannot  be  differentiated  from  that  due  to  achylia,  except  by 
gastric  analysis. 

(c)  Toxemia  Type. — In  the  third  group  are  included  those  cases  of 
acid  catarrh — without  gastric  symptoms,  but  marked  by  severe  recur- 
ring headaches  and  other  manifestations  of  intestinal  toxemia.  The 
headaches  are  periodical,  diffuse,  although  during  the  first  few  hours 
of  onset  they  may  be  hemicranial  in  type,  and  are  commonly  spoken  of 
as  due  to  bilious  attacks.  Scotomas  and  fortification  outlines  do  not 
commonly  occur.  Between  these  acute  attacks  there  may  be  more  or 
less  constant  dull  feeling  of  oppression  in  the  head,  usually  worse  on 
waking  and  passing  away  by  mid-day.  Drowsiness  and  mental  hebe- 
tude frequently  are  present  to  such  a  degree  that  mental  or  physical 
work  is  done  only  by  the  greatest  effort  of  the  will.  In  every  case  of 
"biliousness"  or  of  recurring  "bilious  attacks"  an  examination  of  the 
gastric  contents  should  be  made. 

Differentiation  of  Symytoms. — It  is  curious  that  in  these  three  types 
the  symptoms  are  sharply  defined.  Those  who  complain  of  heart -burn 
are  not  apt  to  have  diarrhea  or  headaches,  nor  do  those  with  diarrhea 
seem  to  be  subject  to  heart-burn  or  intestinal  toxemia.  Those  with 
headaches  are  not  liable  to  suffer  from  gastric  distress  or  diarrhea. 

Aside  from  these  principal  clinical  types,  the  wiiter  has  found  that 
very  indefinite  symptoms  were  presented  in  about  one-fourth  of  the 
cases  in  which  acid  catarrh  is  found  by  gastric  analysis.  There  may 
be  only  a  sense  of  oppression  after  meals,  more  marked  after  hearty  and 
substantial  food,  or  abdominal  discomfort  and  distention,  occurring 
at  any  time  of  day,  but  aggravated  three  or  four  hours  after  the  taking 
of  food.  In  a  certain  number  of  patients  the  only  complaints  were 
that  they  felt  "run  down,"  and  were  constipated.  There  is  nothing 
in  the  clinical  history  of  such  patients  even  to  suggest  acid  gastritis. 
The  diagnosis  can  only  be  made  by  the  examination  of  gastric  contents. 
The  rule  should  be  to  examine  the  stomach  contents  of  all  patients 
with  anemia  and  constipation,  which  prove  rebellious  to  treatment. 
Many  of  these  cases  may  turn  out  to  be  ulcer — only  operation  or 
autopsy  can  decide. 

The  hyperacid  form  is  said  by  German  writers  to  be  especially 
common  after  abuse  of  alcohol,  and  to  represent  the  initial  stage  of  a 
4 


50  CHRONIC  GASTRITIS 

catarrh  which,  as  the  inflammation  progresses,  shows  a  reduction  in 
acidity  passing  from  hyperacidity  to  normal,  from  normal  to  subnormal, 
finally  ending  in  total  absence  of  peptic  power  or  achylia.  The  writer 
ventures  to  express  his  doubts  in  this  matter.  Cases  of  hyperacid 
gastritis  have  been  followed  for  years  and  never  with  any  evidence 
of  their  ever  showing  such  a  reduction  in  their  acidity,  and,  on  the 
other  hand,  of  many  hundred  cases  of  achylia,  there  was  no  evidence 
that  hyperacidity  had  been  the  preceding  condition.  The  writer  be- 
lieves that  hyperacid  cases  remain  hyperacid,  and  that  subacidities 
represent  a  reduction  from  the  normal  without  any  preceding  rise  of 
acid  values. 

II.  Gastritis  with  Normal  Acidity. — Gastritis  with  normal  acidity  oc- 
curred in  24.5  per  cent,  of  the  patients  with  gastritis  seen  in  the  writer's 
private  practice.  It  is  probable  that  the  actual  proportion  of  normal 
acid  cases  is  far  greater  than  this,  as  digestive  symptoms  are  usually  so 
indefinite  that  the  disease  is  unsuspected.  There  are  no  characteristic 
symptoms  of  this  form  of  disorder.  There  is  neither  nausea,  vomiting, 
heart-burn,  pain,  nor  epigastric  distress.  Symptoms  of  intestinal  toxemia 
appear  but  infrequently,  usually  occurring  in  those  cases  only  that 
are  complicated  by  a  coexisting  atony,  and  are  due  rather  to  the  atony 
than  to  the  gastritis  itself.  This  lack  of  symptoms  of  intestinal  auto- 
intoxication is  in  striking  contrast  with  the  frequency  in  which  toxemia 
occurs  in  the  hyperacid  and  anacid  cases.  Diarrhea  does  not  occur  as 
in  the  hyperacid  and  anacid  cases.  Abdominal  distention  and  dis- 
comfort are  but  rarely  observed.  One-fourth  of  the  patients  com- 
plained of  a  symptom  which,  however,  is  not  distinctive — a  peculiar 
gnawing,  empty  feeling  in  the  fasting  state.  These  patients  become 
haggard  and  weary  and  worn  unless  they  eat  frequently.  Similar 
subjective  sensations,  howe\'er,  accompany  the  chronic  forms  of  hyper- 
secretion and  are  of  common  occurrence  in  the  various  forms  of  sensory 
neuroses  of  the  stomach.  In  gastritis  this  sensation  never  amounts  to 
a  pain,  nor  is  it  usually  referred  to  the  epigastrium  as  a  localized 
discomfort,  but  rather  as  a  sense  of  general  physical  and  nervous 
exhaustion. 

Chronic  gastritis  with  an  acidity  that  is  under  the  normal  limits 
runs  the  same  obscure  clinical  course  as  those  in  whom  the  degree  of 
acidity  is  normal.  Sul)acidity  is,  however,  rarer  than  any  of  the  other 
forms — downward  gradation  of  gastric  secretion  does  not  seem  to  be 
gradual,  and  there  are  encountered  comparatively  few  cases  in  which 
the  acidity  occupies  an  intermediate  place  between  that  of  the  normal 
and  that  of  complete  acliylia. 

III.  Gastritis  with  Anacidity  or  Achylia. — The  exact  nature  of  achylia 
is  (juite  obscure,  although  the  disease  is  one  of  common  occurrence, 


CHRONIC  CATARRHAL  GASTRITIS  51 

being  found  by  the  writer  in  1  out  of  every  16  private  patients  that 
apply  for  relief  from  dyspeptic  symptoms.  It  may  occur  as  a  primary 
neurosis,  or  as  the  result  of  inhibition  of  gastric  secretory  reflexes, 
especially  during  the  course  of  gall-bladder  disease.  It  is  frequently  ob- 
served with  cirrhosis  of  the  liver,  and  often  accompanies  general  arte- 
rial degeneration.  It  is  one  of  the  common  causes  for  the  dyspepsia  of 
the  aged,  and  results  from  atrophy  of  the  gastric  tubules  in  pernicious 
anemia  and  in  cancer,  whether  situated  in  the  stomach  or  elsewhere. 
It  is  obviously  wrong,  therefore,  to  describe  all  these  various  forms  as 
the  result  of  gastritis,  for  gastritis  is  but  one  of  the  causes  that  lead  to 
a  cessation  of  the  function  of  secretion  of  the  digestive  fluid  within  the 
stomach.  The  presence  of  mucus  in  the  test  breakfast  has  been  con- 
sidered conclusive  evidence  of  its  origin  in  a  gastric  catarrh,  but  this  is 
not  a  rule  that  can  be  carried  too  far.  The  dryish,  squeezed-out,  undi- 
gested breadstuffs  that  characterize  the  test  breakfast  in  the  majority 
of  cases  of  achylia,  when  placed  in  water,  show  that  mucus  is  generally 
disseminated  in  the  undigested  material,  and  suggests  that  the  un- 
chymified  breadstuffs  may  act  as  a  local  irritant  and  provoke  a  flow 
of  mucus,  which,  though  scanty  in  amount,  is  designed  to  protect  the 
mucous  membrane  from  irritation.  The  writer  includes  under  the  term 
"chronic  gastritis"  only  those  cases  of  achylia  in  which  the  test  break- 
fast shows  undigested  breadstuff s  floating  in  an  abundant  sea  of  gastric 
mucus,  as  well  as  those  instances  of  achylia  in  which  lavage  in  the 
fasting  state  removes  mucus  in  appreciable  quantities. 

Achylia  thus  considered  occurred  in  35.5  per  cent,  of  cases  of  gastritis 
seen  in  the  writer's  private  practice. 

In  hospital  practice  anacid  gastritis  is  relatively  more  frequent  than 
is  observed  in  patients  of  the  higher  walks  of  life. 

Symptoms  of  Anacid  Gastritis. — The  symptoms  of  achylia,  the 
result  of  a  chronic  gastric  catarrh,  do  not  differ  in  any  particular 
whatever  from  those  seen  in  achylia  resulting  from  any  of  the  other 
causes.  To  avoid  unnecessary  repetition  the  reader  is  directed,  there- 
fore, to  the  symptoms  of  achylia  in  general,  on  p.  494. 

Negative  Symptoms  of  Gastritis. — Appetite. — Usually  there  are  no 
changes  in  the  appetite.  The  patients  eat  well  and  enjoy  their  food. 
If  atony  should  exist  as  an  associated  condition  there  may  be  an  early 
sense  of  satiety  at  the  table,  which  renders  it  distasteful  for  the  patient 
to  eat  sufficiently.  In  cases  of  gastritis  occurring  in  neurasthenic 
subjects,  the  appetite  may  be  capricious  and  fickle,  and  may  even 
fail.  In  these  two  instances,  however,  the  failure  of  appetite  is  due  to 
the  associated  condition  and  not  to  the  gastritis  itself. 

Nausea. — Nausea  is  not  a  symptom  of  gastritis.  Neurasthenic  sub- 
jects or  those  with  atony  may  complain  of  a  more  or  less  constant 


52  CHRONIC  GASTRITIS 

nausea,  which  is  not  influenced  by  eating,  and  which  does  not  usually 
prevent  their  normal  enjoyment  of  their  meals  after  they  are  seated 
at  table,  but  gastritis  not  thus  complicated  is  but  very  rarely  accom- 
panied by  nausea  in  the  writer's  experience.  On  the  other  hand, 
Eisner  finds  nausea  in  40  per  cent,  of  his  cases. 

Vomiting. — Neither  is  vomiting  frequent  in  the  non-alcoholic  cases, 
although  it  is  spoken  of  in  the  majority  of  text-books  as  frequent  and 
quite  characteristic.  The  patients  are  said  to  be  nauseated  after 
meals  and  to  vomit  small  quantities  of  food  intimately  admixed  with 
such  tough  mucus  that  the  ejected  matters  stick  tenaciously  to  the 
side  of  the  bowl.  This  has  not  been  noticed  by  the  writer  except  after 
gross  indiscretions  in  diet,  sufficient  to  induce  vomiting  in  anyone 
whose  stomach  is  naturally  sensitive,  no  matter  whether  or  not  chronic 
catarrh  is  present. 

In  those  cases  who  overdrink  or  oversmoke,  there  may  be  morning 
vomiting  of  a  brackish  fluid  that  does  not  give  hydrochloric  acid 
reactions.  This  vomitus  matutinus,  as  it  is  called,  is  simply  the  rejec- 
tion of  the  stomach  of  saliva  and  pharyngeal  mucus  that  has  been 
swallowed  during  the  night,  and  consequent  upon  chronic  pharyngitis. 
It  has  nothing  whatever  to  do  with  any  morbid  condition  within  the 
stomach  itself. 

Pain. — Pain  does  not  ordinarily  occur  in  gastritis.  Exceptions  to 
this  rule  must  be  made,  however,  in  the  rare  cases  of  sclerosing  gas- 
tritis with  pyloric  narrowing,  and  in  a  few  cases  of  chronic  atrophic 
gastritis  in  which  lancinating  pains  of  a  neuralgic  character  may  be  a 
cause  for  complaint.  Associated  atonic  contUtions  of  the  gastric  wall 
may  allow  of  gaseous  accumulation,  which  gives  rise  to  pain,  but  this 
is  due  to  atony  and  not  to  the  gastritis  either  directly  or  indirectly. 
Acid  gastritis  may  be  evinced  by  heart-burn,  amounting  (^ften  to  dis- 
tress, but  this  cannot  properly  be  described  as  pain.  Eructations  or 
accwnulatioii.s  of  f/a.s  in  the  stomach  do  not  occur  in  chronic  (jastritis  that 
is  not  accompanied  by  atony,  but  regularly  are  present  should  this  latter 
condition  exist. 

Emaciation. — Emaciation  is  not  common  in  gastritis,  unless  diarrhea 
be  jjrescnt  or  unless  the  diet  has  been  insufficient.  Progressive  loss  of 
flesh  and  an  increasing  anemia  suggest  the  possibility  of  malignancy. 

Excluding  the  rare  cases  of  sclerosing  gastritis  in  which  gradual 
narrowing  of  the  jjyloric  aperture  occurs,  chronic  gastritis  regularly 
runs  its  course  without  any  diminution  in  the  motor  strength  of  its 
walls,  or  any  retanlation  of  the  time  in  which  the  gastric  contents  leave 
the  stomach.  \'oniiting  of  fcjod  too  long  retained  does  not  occur, 
neither  are  ])resent  evidences  of  any  of  the  forms  of  hypersecretion, 
either  clinically  or  by  examination  of  gastric  contents. 


CHRONIC  CATARRHAL  GASTRITIS  53 

Atony  does  not  occur  as  the  result  of  a  gastric  catarrh,  no  matter 
how  intense  the  inflammation  may  he,  but  it  is  not  infrequently  observed 
as  an  associated  and  independent  condition.  When  atony  is  present, 
gastric  flatulence  appears,  giving  rise  to  eructations  and  to  gaseous 
accumulations  in  the  stomach,  often  accompanied  by  some  degree  of 
distention  pain.  The  appetite  is  easily  satisfied,  and  the  symptoms  of 
intestinal  toxemia  become  accentuated. 

Diagnosis. — Gastric  Analysis. — The  diagnosis  of  chronic  catarrh  of 
the  stomach  cannot  be  made  without  the  use  of  the  stomach-tube. 
By  gastric  analysis  many  suspected  cases  prove  to  have  normal  gastric 
contents,  and  are  to  be  classed  among  the  neuroses,  while  in  other 
cases,  evidences  of  tj^ical  gastric  catarrh  are  present  when  they  are 
least  expected. 

1 .  Gastric  analyses  should  always  be  made  in  every  case  of  dyspepsia, 
no  matter  whether  these  symptoms  be  apparently  gastric  or  intestinal, 
unless,  of  course,  contra-indication  to  the  passage  of  the  tube  exists. 

2.  Gastric  analyses  should  be  made  in  every  case  of  chronic  diarrhea 
that  is  not  due  to  evident  disease  of  the  colon  or  rectum. 

3.  Gastric  analyses  should  always  be  made  in  all  cases  of  intestinal 
toxemia,  of  recurring  headaches  of  toxic  origin,  and  in  patients  who 
complain  of  the  symptom-complex  which  is  spoken  of  by  the  laity  as 
biliousness. 

4.  Gastric  analyses  should  be  made  in  all  cases  of  anemia  and  general 
physical  wretchedness  without  known  cause  and  which  are  rebellious 
to  treatment. 

Examinations  should  be  made  both  of  the  fasting  and  of  the  digesting 
stomach.  The  wTiter's  procedure  is  as  follows:  The  patient  eats  his 
evening  meal  as  usual.  Between  10  and  11  p.m.  he  is  directed  to  con- 
sume a  meat  sandwich,  preferably  of  roast  beef,  although  any  kind 
of  meat  will  be  satisfactory,  and  to  drink  a  glass  of  water.  Thereafter 
nothing  is  to  be  taken,  not  even  a  sip  of  water,  until  the  following 
morning,  when  between  8.30  and  9  the  tube  is  passed  and  the 
contents,  if  any,  are  withdrawn.  No  water  is  to  be  introduced  at  the 
time. 

The  patient  is  then  given  a  breakfast  roll,  or  an  ecj[uivalent  quantity 
of  bread  without  butter,  and  a  glass  of  water.  One  hour  after  the 
beginning  of  such  a  meal  (not  one  hour  after  its  completion)  the  tube 
is  again  passed  and  the  contents  of  the  stomach  are  drawn  into  an 
aspiration  bulb  (Fig.  6).  The  use  of  the  bulb  is  preferable  to  the 
trusting  of  gagging  efforts  to  force  the  gastric  contents  of  the  stomach 
through  the  tube  into  the  receiving  bulb.  If  mucus  be  present  in  the 
test  breakfast  the  bulb  is  quickly  detached  and  a  larger  one,  shaped 
like  a  Politzer  bag,  that  contains  200  c.c.  of  water,  is  substituted,  the 


54 


CHRONIC  GASTRITIS 


water  rapidly  expressed  through  the  tube  into  the  stomach,  and  at 
once  aspirated  and  the  tube  withdrawn.  Withdrawal  of  the  test 
breakfast  should  not  take  more  than  fifteen  seconds  from  the  time  of 


Stomach-tube  and  aspirating  bulb  for  extraction  of  gastric  contents.  Compression  of  the  bulb  with 
pinching  the  distal  tube  at  A  and  then  relaxing  the  pressure  on  the  bulb  serves  as  the  vacuum.  Releas- 
ing pressure  on  the  distal  tube,  pinching  the  proximal  tube  at  B,  and  compressing  the  bulb  expel  the 
aspirated  contents  into  a  graduate. 


Fig. 


Poiitzcr  bag  for  experinicMtul  lavage. 


the  passage  of  the  tube  until  its  re- 
moval, and  the  ex])erimental  lavage 
by  the  method  just  described  should 
not  increase  the  length  of  ordeal 
more  than  an  equal  length  of  time. 
The  reason  why  the  writer  recom- 
mends this  experimental  lavage  is 
that  in  many  cases  of  catarrh  the 
contents  of  the  stomach  are  so 
thickened  by  tenacious  mucus  that 
they  are  not  readily  withdrawn 
through  a  tube.  It  has  repeatedl\- 
happened  that  the  withdrawal  of 
the  test  breakfast  shows  only  a 
small  quantity  of  apparently  well- 
digested  breadstuffs  without  mucus, 
while  in  the  return  of  the  lavage, 
mucus  and  food  in  large  masses  mixed 
with  tenacious,  glairy  mucus  are 
withdrawn.  Should  nnicus  a])])ear 
with   the  exi)erimental  lavage  given 


CHRONIC  CATARRHAL  GASTRITIS  55 

in  this  manner,  just  after  the  withdrawal  of  the  test  breakfast,  it 
is  often  desirable  to  ask  the  patient  to  return  before  l)reakfast  on  a 
subsequent  morning  for  lavage — to  determine  whether  mucus  is 
secreted  at  all  times,  or  only  during  the  physiological  congestion  that 
accompanies  digestion. 

Gastric  Analysis  in  Gastritis  with  Increased  Acidity. — Examination  in 
the  fasting  state  may  exceptionally  show  that  the  stomach  is  empty. 
Usually,  however,  there  are  withdrawn  from  10  to  25  c.c.  of  a  thin,  viscid 
mucus,  often  slightly  acid  in  reaction,  although  the  presence  of  free 
hydrochloric  acid  cannot  usually  be  demonstrated.  Hypersecretion  is 
not  a  coinplicaiion  of  chronic  catarrh.  Food  remains  are  not  found  in 
the  fasting  stomach  even  in  microscopical  proportions. 

The  muscular  power  of  the  stomach  in  uncomplicated  gastritis  is 
uniformly  good,  and  signs  of  pyloric  stenosis  and  food  stagnation  do 
not  occur  except  with  the  stenosis  form,  to  which  special  reference  will 
be  made. 

Lavage  usually  but  not  invariably  brings  quantities  of  ropy  mucus. 

The  test  breakfast  consists  of  breadstuffs  more  or  less  imperfectly 
chymified,  and  intimately  intermixed  with  mucus.  It  is  important  to 
differentiate  between  pharyngeal  mucus  that  has  been  swallowed  and 
appears  in  the  test  breakfast  and  that  form  which  is  of  gastric  origin. 
Pharyngeal  mucus  is  grossly  and  coarsely  intermixed  with  food  par- 
ticles, is  of  a  lumpy  consistency,  floats  on  the  surface  of  the  test  break- 
fast, and  can  be  drawn  to  one  side  in  a  thick  mass  by  a  hook.  When  it 
has  been  thus  drawn  aside  the  bulk  of  the  test  breakfast  is  disclosed 
of  a  more  homogeneous  consistency,  and  if  gastric  mucus  be  present,  it 
will  be  seen  to  be  uniformly  and  intimately  admixed  with  the  food 
particles.  The  floating  pharyngeal  mucus  may  be  raised  from  the  sur- 
face of  the  test  breakfast  in  masses  of  considerable  size,  while  gastric 
mucus  cannot  be  elevated  to  any  great  distance  by  a  hook.  The  test 
breakfast  on  standing  does  not  usually  separate  into  two  layers,  of 
clear  fluid  and  of  food  debris,  unless  atony  coexists,  in  which  case  the 
depth  of  the  two  layers  is  equal.  More  marked  degrees  of  alimentarj' 
hypersecretion  than  this  do  not  occur  with  gastritis. 

The  total  acidity  ranges  from  normal  to  75  to  85.  Acidities  higher 
than  this  are  rare,  and  should  suggest  the  possibility  of  ulcer.  The 
proportion  of  free  hydrochloric  acid  to  the  total  acidity  is  practically 
that  of  the  normal  test  breakfast.    Occult  bleeding  does  not  occur. 

The  stomach  contents  of  chronic  gastritis  are  distinguished  by  the 
absence  of  organic  acids — lactic  acid  does  not  occur.  ]Many  writers 
speak  of  various  forms  of  organic  fermentation  encountered  in  gas- 
tritis, and  of  the  presence  of  fatty  acids  and  of  lactic  acid.  This  is 
entirely  contrary  to  the  writer's  experience. 


56 


CHRONIC  GASTRITIS 


Lab-ferment  is  present.  No  conclusions  can  be  drawn  by  the  various 
methods  of  determining  the  strength  of  peptic  digestion  in  these  eases. 
Microscopically  the  presence  of  many  leukocytes  and  epithelial  cells 
of  the  gastric  mucosa  enmeshed  in  gastric  mucus  affords  positive 
evidence  of  gastric  catarrh. 

Cohnheim  and  others  describe  the  valuable  aid  in  diagnosis  afforded 
by  the  finding  of  bits  of  mucous  membrane  in  the  lavage  water  or  in 
the  test  breakfast.  The  writer  warns  against  placing  too  much  con- 
fidence in  the  microscopic  examination  of  these  fragments,  as  too 
many  sources  for  error  are  possible.     These  exfoliations  are  said  to 


Fig.  8 


Test  breakfast  of  chrDiiic  hyperacid  gastritis.    The  supernatant  fluid  layer  is  of  glassy  mucus  which 
can  be  raised  on  a  hook.    The  bread  particles  are  imperfectly  chymified  and  flocculent. 


be  common  in  chronic  gastric  catarrh,  although  not  confined  to  this 
disease.  The  writer  believes  that  the  greater  the  care  taken  to  select 
a  stomach-tube  with  openings  that  have  smooth,  rounded  edges  the 
fewer  of  these  fragment  bits  are  found.  The  sharp,  punched-out  aper- 
tures in  many  of  the  cheaper-made  tubes  often  inflict  traumatism  on  the 
gastric  iiukoiis  membrane,  which  results  in  the  cutting  or  tearing  off 
of  small  bits  of  living  tissue. 

Gastric  Analysis  in  Gastritis  with  Normal  Acidity. — The  examination 
of  the  fasting  state  and  of  the  test  breakfast  is  the  same  as  that  of  the 
acid  form,  dillering  from  it  only  in  that  the  total  acidity  and  free 


CHRONIC  CATARRHAL  GASTRITIS 


57 


hydrochloric  acid  are  present  in  normal  amounts.  The  lower  the  total 
acidity  and  the  amount  of  free  hydrochloric  acid  the  greater  is  the 
reduction  of  peptic  power,  so  that  disks  of  albumin  placed  in  the 
filtered  gastric  contents  are  dissolved  slowly  or  not  at  all. 

Gastric  Analysis  in  Gastritis  with  Anacidity. — Achylia. — In  achylia  the 
fasting  stomach  is  usually  empty,  although  small  quantities  of  gastric 
mucus  may  be  found.  The  fact  that  motor  errors  do  not  exist  is  of 
the  greatest  value  in  differentiating  this  disease  from  cancer,  in  which 
evidences  of  stagnation  either  in  the  fasting  or  in  the  digesting  stomach 
are  found  in  nearly  three-fourths  of  all  the  patients. 

Fig.  9 


IBBB 

i 

^^^K^^^ 

si 

Normal  test  breakfast.    A  moderate  layer  of  supernatent  fluid  would  have  formed  had  the  specimen 

been  allowed  to  stand. 


The  test  breakfast  in  achylia  occurs  in  any  one  of  three  forms: 

1.  The  first  and  more  frequent  is  the  dry  form  in  which  the  bread 
fragments  have  a  dry,  squeezed-out  appearance,  and  look  as  if  they 
had  been  chewed  and  spat  out  again. 

2.  The  second  variety  is  that  of  an  apparently  normal  test  breakfast, 
although  it  has  not  the  smooth,  puree  consistency  of  the  normal,  but 
is  more  coarsely  granular. 

It  is  improbable  that  either  of  these  two  forms  are  /ound  in  achylia 
that  is  due  to  gastric  catarrh — they  are  seen  in  the  other  varieties  of 
achylia  and  are  fully  described  in  the  article  on  that  affection,  in  which 
the  various  types  are  discussed  in  detail  (see  p.  503). 

3.  The  form  of  test  breakfast  that  is  indicative  of  gastric  catarrh  is 
known  as  the  "wet  variety  of  achylia."  The  test  breakfast  consists  of 
poorly  chymified  breadstuflTs  floating  in  a  sea  of  mucus,  the  quantity 


58 


CHRONIC  GASTRITIS 


varying  from  2  to  S  ounces.  The  mucus  may  appear  only  in  the  con- 
tents of  the  digesting  stomach,  as  is  shown  by  the  fact  that  lavage 
in  the  fasting  state  shows  the  stomach  to  be  perfectly  clean.  The 
total  acidity  is  negligible — hydrochloric  acid  in  either  free  or  com- 
bined form  cannot  be  detected  by  chemical  tests,  and  the  peptic  power 
of  the  filtrate  is  practically  nil.  Lab-enzyme  is  inactive.  There  have 
been  attempts  made  to  estimate  the  degree  of  damage  done  by  the 
inflammatory  process  to  the  secretory  apparatus  of  the  stomach  by 
determining  the  activities  of  the  lab-zymogen.  The  following  is  a 
convenient  method  of  testing  quantitative  reactions  of  lab-zymogen. 


Test  breakfast  in  chronic  anacid  gastritis.  The  undigested  breadstufYs  are  seen  floating  in  the  mucus, 
and  settling  leave  a  supernatant  layer.  To  bo  contrasted  with  the  normal  test  breakfast  shown  in 
Fig.  9. 


One  cubic  centimeter  of  filtered  gastric  juice  is  introduced  into 
a  graduated  measure  of  10  c.c.  capacity,  water  to  the  10  c.c.  mark 
is  added,  and  the  mixture  is  shaken  several  times.  Five  cubic 
centimeters  of  the  admixture  are  then  withdrawn  by  a  pipette,  placed 
in  a  beaker  and  marked  "1  to  10."  The  examiner  should  now  add 
water  to  the  5  c.c.  which  remain  in  the  graduate  until  it  again  reaches 
the  10  c.c.  mark.  Five  cubic  centimeters  of  this  mixture  are  to  be 
withdrawn  and  marked  "  1  to  20."  This  dilution  of  the  original  1  c.c. 
of  gastric  juice  should  be  repeated  and  the  dilutions  marked  "  1  to  40," 
"1  to  80,"  "1  to  1()0,"  "1  to  320."  To  each  beaker  containing  such 
diluted  gastric  juice  are  added  5  c.c.  of  milk  and  2.5  c.c.  of  a  1  per 
cent,  calcium  chloride  solution  and  the  specimens  set  in  a  bacterial 
oven  or  water  bath   at   102°  to   104°. 


CHRONIC  CATARRHAL  GASTRITIS  59 

Normally,  dilutions  of  1  to  160  show  a  firm  cake-like  coagulation, 
dilutions  of  1  to  320  are  fine  and  flaky. 

If  in  a  given  case  of  achylia  normal  coagulation  by  lab-zymogen 
occurs  and  firm  coagulation  appears  with  dilutions  of  1  to  100,  par- 
ticularly if  this  be  the  result  of  repeated  examinations,  it  is  improbable 
that  an  organic  affection  of  the  stomach  is  present. 

If  the  zymogen  be  diminished  one-half  in  its  activity  a  mild  catarrhal 
process  is  probably  present,  and  restitution  by  appropriate  treatment 
is  to  be  expected. 

If  zymogen  reaction  be  absent  in  dilutions  of  1  to  10  or  1  to  20, 
there  probably  exists  a  grave  and  usually  incurable  catarrh  or  atrophy 
of  the  gastric  tubules. 

Course  and  Duration. — The  duration  of  chronic  gastritis  may  extend 
over  years,  and  although  a  "clinical"  cure  is  to  be  expected,  and  the 
patient  relieved  of  all  distress,  a  restitutio  ad  integram  cannot  be  hoped 
for.  When  the  existing  cause  is  found  in  some  gross  and  palpable  error 
in  diet  or  in  the  habits  of  life  that  can  be  corrected,  the  greater  are  the 
chances  of  relief  when  these  etiological  factors  can  be  eliminated. 
When  there  are  no  bad  habits  to  throw  away  we  are  working  more  in 
the  dark,  and  our  results  are  not  quite  as  good.  The  most  favorable 
cases  for  treatment  are  those  of  the  acid  form  because  the  actual  diges- 
tive power  of  the  stomach  is  good;  there  are  inflammatory  changes 
present,  but  functional  activity  of  the  stomach  is  unimpaired.  In  sub- 
acidity  and  achylia  the  digestion  is  mainly  carried  on  in  the  intestine, 
and  much  depends  upon  whether  or  not  the  intestine  is  in  a  condition 
to  do  its  work.  Enteritis,  which  often  accompanies  achylia,  regularly 
prolongs  the  duration  of  the  disease  and  retards  the  clinical  cure. 
Subacid  or  anacid  cases  with  the  preservation  of  normal  lab-zjmogen 
reactions  may  generally  be  regarded  as  favorable  subjects  for  treatment. 

Treatment. — Prophylactic  Treatment. — This  is  the  most  important  of 
all,  and  consists  in  the  correction  of  all  causes  which  have  had  any 
influence  in  producing  or  aggravating  the  gastric  catarrh.  Dietetic 
errors  must  be  detected  and  corrected  regularity  and  a  reasonable 
uniformity  of  the  meals  insisted  on.  If  the  patient  should  insist  that 
he  eats  only  the  simplest  and  most  wholesome  food,  and  that  he  is 
regular  and  temperate  in  his  habits,  it  is  often  well  to  have  him  keep 
for  a  week  a  written  list  of  everything  he  eats  and  drinks  and  the 
actual  time  of  his  meals,  to  which  may  be  added  an  account  of  what 
he  does  during  the  day.  The  physician  can  often  obtain  more  real 
information  about  his  patient  by  such  a  record  than  in  any  other  way. 
Slow  eating  and  perfect  mastication  are  to  be  insisted  on,  and  all  defec- 
tive conditions  of  the  teeth  that  render  mastication  difficult  should 
be  corrected.     The  teeth  should   be  kept  thoroughly   cleansed,   and 


60 


CHRONIC  GASTRITIS 


local  applications  made  if  Ring's  disease  be  present.  Moderate  smoking 
is  not  injurious,  but  it  should  not  be  carried  to  excess.  The  chewing 
of  tobacco  should  be  prohibited.  If  there  be  a  misuse  of  drugs  and 
carthartics,  these  should  be  either  abandoned  or  greatly  reduced,  and 
the  desired  effect  for  which  they  were  taken  obtained  in  other  less 
harmful  ways. 

Dietetic  Treatment. — A  number  of  diet  lists  have  been  recommended 
in  gastritis,  based  ui)on  the  digestibility  of  the  various  articles  of  food 
included  in  the  list,  their  blantl  non-irritating  quality,  and  the  short 
time  they  remain  within  the  stomach  before  they  pass  through  the 
pylorus  in  a  perfectly  digestefl  state.  Penzoklt,  in  conjunction  with 
other  clinicians,  has  elaborated  a  progressive  diet  for  use  in  gastritis 
which  complies  with  the  above  conditions,  and  becomes  more  liberal 
as  convalescence  is  established.  Penzoldt's  progressive  diet  is  as 
follows: 

Diet  I  (About  Ten  Days) 


Largest 

Food  or  diink. 

amount  at 
one  time. 

Preparation. 

Special  requirements. 

How  to  be  eaten. 

Meat-broth. 

250  gm. 
(\  liter). 

From  beef. 

Without    fat,    not 
salted,  or  only  a 
little. 

Slowly. 

Cows'  milk. 

250  gm. 

Well   boiled   or 

Entire  milk   (or 

If  desired,  with 

(i  liter). 

sterilized. 

lime    water   ^, 
milk  1). 

a  little  tea. 

Eggs. 

One  or 

Very  soft,  just 

Fresh. 

If    taken    raw 

two. 

heated,  or 
raw. 

it    should   be 
stirred     into 
the  warm,  not 
boiling,  meat- 
broth. 

Meat    solution 

30    to    40 

Should  have  only  a 

In   teaspoonful 

(Leube- 

gm. 

slight  meat-broth 

doses     or 

Rosenthal). 

odor. 

stirred      into 
meat-broth. 

Crackers    (Al- 

Six. 

Without  sugar. 

Not     softened, 

bert  biscuits). 

but    well 
chewed     and 
insalivated. 

Water. 

i  liter. 

Ordinary  water,  or 
natural    carbon- 
ated  water  with 
a  small  jiercentage 
of  CO  (Selters). 

Not  too  cold. 

CHRONIC  CATARRHAL  GASTRITIS 


61 


Diet  II  (About  Ten  Days) 


Largest 

Food  or  drink. 

amount  at 
one  time. 

Preparation. 

Special  requirements. 

How  to  be  eaten. 

Calves'  brain. 

100  gm. 

Boiled. 

Freed  from  all 
membranes. 

Best  taken  in 
meat-broth. 

Calves'  thymus. 

100  gm. 

Boiled. 

Likewise,  especially 
carefully  isolated. 

Best  taken  in 
meat-broth. 

Pigeon. 

One. 

Boiled. 

Only  young,  with- 
out skin,  tendons, 
and  the  like. 

Best  taken  in 
meat-broth. 

Chicken. 

As  large  as 

Boiled. 

Only  young,  with- 

Best  taken   in 

a  pigeon. 

out  skin,  tendons, 
and  the  like  (small 
fattened  chicken) . 

meat-broth. 

Raw  beef. 

100  gm. 

Chopped     fine, 

From    the   tender- 

To    be     eaten 

or  scraped, 

loin. 

with  crackers. 

with    only    a 

little  salt. 

Raw    beef- 

100  gm. 

Without     addi- 

A little  smoked. 

To     be     eaten 

sausage. 

tion. 

with  crackers. 

Tapioca. 

30  gm. 

With    milk, 
cooked  to 
make  gruel. 

Diet  III  (About  Eight  Days) 


Largest 

Food  or  drink. 

amount  at 
one  time. 

Preparation. 

Special  requirements. 

How  to  be  eaten. 

Pigeon. 

One. 

Broiled     with 
fresh    butter, 
not  too  much 
seasoning. 

Only  young,  with- 
out skin,  tendons, 
and  the  like. 

Without  grayy. 

Chicken. 

One. 

Broiled     with 
fresh    butter, 
not  too  much 
seasoning. 

Only  young,  wdth- 
out  skin,  tendons, 
and  the  like. 

Without  gra^^. 

Beefsteak. 

100  gm. 

With    fresh 
butter,     rare 
(Enghsh  style) 

The  meat  from  the 
tenderloin,     well 
beaten. 

Without  gravy. 

Ham. 

100  gm. 

Raw,     scraped 

Weakly    smoked, 

With     white 

fine. 

without  the  bone. 

bread. 

Milk-bread  or 

50  gm. 

Baked  crisp. 

Stale     (so-called 

Carefully 

Zweibach  or 

rolls,  etc.). 

chewed,    well 

pretzels. 

insalivated. 

Potatoes. 

50  gm. 

Mashed    or 
boiled  in  salt 

They     should     be 
mealy,  and  should 

water. 

crumble  on  crush- 
ing. 

Cauliflower. 

50  gm. 

As  a  vegetable, 
boiled  in  salt 

Only  flowers  are  to 
be  used. 

water. 

62 


CHRONIC  GASTRITIS 


Diet  IV  (About  Eight  to  Fourteen  Days) 


Largest 

Food  or  drink. 

amount  at 
one  time. 

Preparation. 

Special  requirements. 

How  to  be  eaten. 

Venison. 

100  gm. 

Roasted. 

Saddle,    not    too 
fresh,  but  without 
"hautgout." 

Partridge 

One. 

Broiled  without 

Young    birds, 

(quail). 

bacon. 

without  skin,  ten- 
dons,   legs,    etc.; 
should  hang  for  a 
time. 

Roast  beef. 

100  gm. 

Medium  to  rare. 

From  good,  fatted 
cattle;   well 
beaten. 

Warm  or  cold. 

Tenderloin. 

100  gm. 

Medium  to  rare. 

From  good,  fatted 
cattle;     well 
beaten. 

Warm  or  cold. 

Veal. 

100  gm. 

Roasted. 

From  good,  fatted 
cattle;     well 
beaten. 

Warm  or  cold. 

Pike,  shad, carp, 

100  gm. 

Boiled   in   salt- 

All   fish-bones 

In    the   fish 

trout. 

water,  without 
addition. 

should    be    care- 
fully removed. 

gravy. 

Caviar. 

50  gm. 

Raw. 

Salted  a  little 
(Russian  caviar). 

Rice. 

50  gm. 

Mashed,  pushed 
through  a 
.sieve. 

Soft,  boiled  rice. 

Asparagus. 

50  gm. 

Boiled. 

Soft,    without    the 
hard  part. 

With     a    little 
melted  butter. 

Scrambled  eggs. 

Two. 

With     a    little 
fresh     butter 
and  salt. 

Omelet  (souffle). 

Two. 

With     20     gm. 

Must    have    risen 

To  be  eaten  at 

sugar. 

well. 

once. 

Stewed  fruit. 

50  gm. 

From   fresh 
boiled     fruit, 
to  be  strained 
through  a 
sieve. 

Free  from  all  ker- 
nels and  peel. 

Red  wine. 

100  gm. 

Light,     pure 
Bordeaux. 

Or      some      corre- 
sponding kind  of 
red  wine. 

Slightly  warm. 

The  disadvantage  of  such  a  diet  is  that  although  it  is  so  simple  and 
so  easily  digestible  that  it  reduces  the  irritation  of  the  inflamed  mucous 
membrane  to  a  minimum  it  is  not  sufficiently  adapted  to  the  needs  of 
each  individual  case. 

In  every  case  of  gastritis  the  motor  (iiid  the  secretory  finirt ions  must  Ijc 
spjKirately  considered,  and  a  diet  should  be  individualli/  and  sperificaili/ 
ordered,  which  in  quantity  conserves  the  motor  power,  should  motor  error 
exist,  and  which  in  quality  is  capable  of  being  digested  by  the  digestive 
juices  of  that  individual  patient.    Furthermore,  the  diet  should  be  varied, 


CHRONIC  CATARRHAL  GASTRITIS  63 

should  be  as  mixed  and  general  as  possible,  and  should  be  practical 
for  that  patient  to  obtain  and  to  continue  in  his  own  sphere  of  life. 

Motor  errors  in  gastritis  rarely  exist,  so  that  food  may  be  taken  in 
fair  and  sufficient  quantities.  Frequent  feedings  need  not  be  insisted 
upon  in  these  cases. 

When  atony  coexists,  frequent  small  meals  are  indicated,  the  food 
should  be  given  in  as  concentrated  a  form  as  possible,  and  liquids  at 
meals  are  to  be  restricted.  All  motor  errors  contra-indicate  the  extensive 
general  use  of  mineral  waters  as  a  means  of  cure. 

More  important  is  the  regulation  of  the  diet  to  accord  with  the 
secretory  errors  that  may  be  present. 

Diet  in  Hyperacid  Gastritis. — The  diet  in  hyperacid  gastritis 
should  obviously  be  different  from  that  advised  in  achylia.  In  the 
hyperacid  forms  of  gastritis,  the  peptic  power  may  be  considered 
normal,  and  foodstuffs  may  be  given  in  normal  proportions,  or  even 
proteids  and  fats  allowed  somewhat  in  excess  of  the  quantities 
that  are  usual  in  an  average  mixed  diet.  Meats  that  have  a  tough 
fiber  are  generally  unadvisable,  and  should  be  replaced  by  those  of 
more  tender  character,  such  as  fish,  chicken,  fowl  of  any  kind  except 
goose,  veal,  lean  ham,  or  tender  lamb.  All  scratchy  articles  of  diet 
are  to  be  prohibited,  and  all  overspiced  and  highly  seasoned  food. 
Smoking  must  be  indulged  in  only  after  meals,  and  even  then  never  to 
excess.  Alcohol  in  any  form  is  injurious,  but  if  the  patient  be  accus- 
tomed to  its  use,  it  may  not  be  wdse  to  cut  it  off  altogether,  but  to  allow 
a  little  whisky  and  water  or  a  light,  dry  wine  at  the  meals.  Alcohol 
should  never  be  taken  between  meals,  nor  at  any  time  should  cham- 
pagne, sweet  wines,  or  such  heavy  wines  as  Burgundy  be  allowed. 
Beer  and  ale  are  distinctly  injurious. 

Writer's  Hyperacid  Gastritis  Diet. — Breakfast. — Coffee  not  advised; 
no  tea  allow^ed;  no  coarse  cereal,  such  as  oatmeal  or  cracked  wheat; 
no  bread  crusts,  dry  toast,  or  hot  bread;  no  salt  fish  or  potatoes. 

Allowed:  Cocoa,  with  cream  and  sugar.  Fine  cereal,  such  as  cream 
of  wheat,  farina,  etc.  Soft  parts  of  bread,  milk  or  cream  toast.  Crackers, 
thoroughly  masticated.  Butter,  preferably  unsalted,  to  be  taken  as 
freely  as  possible.  Creamed  or  minced  chicken;  fresh  fish;  soft-boiled 
or  poached  eggs. 

Luncheon. — Puree  or  cream  soup  of  any  kind,  made  without  meat 
stock;  no  other  soups  allowed.  Lamb;  simply  prepared  ragout;  lean 
broiled  or  boiled  ham;  fish,  chicken,  oysters  in  any  form.  Fowl, 
except  domestic  duck  or  goose.  Mashed  or  baked  potatoes;  spaghetti 
or  macaroni.  Any  vegetable  that  can  be  put  through  a  puree  sieve 
allowed.  Any  green  vegetable  (such  as  string  beans)  may  be 
taken  if  tender,  not  if  tough.    Salad,  with  French  dressing,  made  with 


64  CHRONIC  GASTRITIS 

lemon.  Farinaceous  desserts,  such  as  rice  pudding,  corn-starch,  blanc- 
mange, custard,  etc.  No  ice-cream  or  ices.  No  fruit  of  any  kind. 
Alcohol  not  allowed  in  any  form. 

Cheese:  Camembert,  Roquefort,  Cream,  Brie,  Neufchatel,  pot- 
cheese. 

Dinner. — Same  variety  as  for  lunch. 

Between  meals  may  be  taken:  Choice  of  custard,  junket,  raw  eggs 
or  egg-and-milk  shake,  chicken  or  meat  sandwich;  malted  milk,  cocoa. 
Milk  in  the  glass  not  allowed. 

Seasoning,  such  as  pepper,  salt,  paprika,  etc.,  should  be  reduced  to 
the  minimum. 

Water  should  be  cool  but  not  iced;  Celestins  or  Saratoga  Vichy, 
Fachingen,  Apollinaris,  or  Giesshuebler  are  preferable  to  plain  water; 
when  these  waters  cannot  be  obtained,  may  drink  water  containing 
one-fourth  of  a  teaspoonful  of  bicarbonate  of  soda  to  the  glass. 

The  Diet  in  Gastritis  with  Normal  Acidity. — This  difl'ers  from 
the  preceding  in  one  particular  only — that  proteid  food  should  be 
given  in  somewhat  smaller  quantities.  As  a  rule,  meats  should  be 
allowed  but  once  daily,  as  the  peptic  power  in  these  cases  is  more  or 
less  diminished.    An  increase  in  fats  is  not  to  be  advised. 

Diet  in  Achylia. — The  diet  should  consist  theoretically  and  chiefly 
of  carbohydrates  and  starches,  with  a  greatly  diminished  amount  of 
proteids  and  fats.  Practically  the  diet  can  be  made  somewhat  more 
liberal  than  this  as  intestinal  and  pancreatic  digestion  may  compensate 
for  the  loss  of  peptic  power.  The  full  details  of  the  achylia  diet  are 
given  in  a  later  chapter  (see  Achylia,  p.  50G). 

Medicinal  Treatment. — This  may  be  administered  either  by  drugs 
or  by  mineral  waters. 

The  drugs  that  are  of  service  in  chronic  catarrh  of  the  stomach  are 
very  few,  and  their  results  are  disappointing  and  uncertain.  In  the 
hyperacid  forms,  belladonna  has  been  generally  advised  to  reduce  over- 
secretion.  It  should  be  continued  in  doses  well  under  physiological 
limits  for  a  considerable  length  of  time.  The  writer  has  given  this 
drug  a  fair  trial,  and  has  never  been  satisfied  that  it  has  done  the 
least  amount  of  good. 

Silver  nitrate  may  often  be  of  service.  It  may  be  given  in  doses  of 
\  grain,  in  distilled  water  before  eating,  or  in  pill  or  (•a])sule.  A  service- 
able prescription  is  as  follows: 

I^ — Argenti  nitrat gr.  ss 

Ext.  hyoscyami  ale gr.  ss — M. 

Ft.  cap.s.  no.  j. 

Sig. — One  between  meals. 


CHRONIC  CATARRHAL  GASTRITIS  65 

Lavage  with  1  to  3000  solution  of  the  silver  salt,  every  second 
day,  may  be  given  as  in  chronic  indolent  ulcer.  In  very  severe  cases, 
especially  if  the  diagnosis  from  ulcer  is  difficuli,  an  ulcer  cure  should  he 
advised. 

Alkaline  Powders. — Alkaline  powders  may  be  used  to  neutralize 
the  excessive  acidity  and  to  regulate  the  bowels.  If  the  bowels  are 
regular  the  basis  of  the  powder  should  be  sodium  bicarbonate,  to 
which  sodium  citrate  may  be  added.  If  the  patient  be  constipated, 
calcined  magnesia  should  be  added  to  the  list  of  alkaline  ingredients, 
while  in  cases  of  diarrhea  calcium  carbonate  and  bismuth  subcarbonate 
are  to  be  employed. 

In  h}'peracid  cases,  olive  or  sweet  almond  oil  or  liquid  paraffin  may 
be  taken  before  meals  in  teaspoonful  doses.  If  preferred,  oil  can  be 
given  in  the  form  of  emulsion. 

If  hydrochloric  acid  be  deficient,  acids  are  indicated,  either  the  dilute 
hydrochloric  acid,  or  in  the  form  of  acidol  tablets  or  oxyntin.  Pepsin 
is  often  prescribed,  as  are  the  digestive  ferments.  Secretin  has  seemed 
to  the  writer  to  be  of  great  service  in  these  cases.  The  medicinal 
treatment  of  these  cases  of  achylia  is  given  in  detail  on  p.  508. 

Mineral  Waters. — The  treatment  of  gastritis  by  the  use  of  mineral 
waters,  either  at  home  or  at  the  appropriate  "cure,"  is  a  form  of  treat- 
ment more  in  vogue  in  Germany  than  in  the  United  States.  It  should 
be  more  frequently  employed  by  us  than  it  is,  although  there  is  no 
doubt  but  that  better  results  are  obtained  at  the  "cure"  than  by  the 
use  of  the  same  water  at  home.  The  freedom  from  business  cares  and 
worries,  and  the  fresh-air  exercise  and  relaxation,  conduce  greatly  to 
beneficial  results,  but  beside  these  evident  advantages,  mineral  water 
fresh  from  the  spring  certainly  has  a  more  beneficial  effect  than  the 
same  water,  bottled  and  imported,  and  vastly  more  than  any  form  of 
artificial  water  made  by  the  addition  of  powders  compounded  in  the 
chemist's  laboratory  or  obtained  by  the  evaporation  of  the  original 
water  fresh  from  the  spring.  Nevertheless,  bottled  waters  may  be 
taken  at  home  with  advantage,  and  even  may  be  artificially  prepared. 
The  choice  of  mineral  waters  should  be  carefully  considered  and 
never  advised  unless  after  due  consideration  of  motor  and  secretory 
conditions.  Motor  errors,  if  present,  contra-indicate  their  general  use. 
Cases  with  atony  should  not  be  sent  to  drink  the  waters  escept  in  small 
quantities  at  a  time,  and  only  under  medical  advice;  and  in  no  case 
should  more  than  a  glass  be  given  at  a  time,  never  more  than  three 
glasses  daily,  and  never  within  two  hours  after  a  meal,  nor  one  hour 
before  the  patient  eats  again. 

The  next  important  consideration  is  that  of  gastric  acidity.    There 
are  three  general  classes  of  mineral  waters  that  may  be  selected. 
5 


66  -CHRONIC  GASTRITIS 

Carlsbad  is  indicated  in  gastritis  with  increased  production  of  mucus, 
with  high  acidity.  The  water  is  to  be  given  warm  or  hot,  the  hotter 
it  is  the  less  effect  it  seems  to  have  upon  the  bowels.  If  constipation 
persists  it  may  be  given  cool.  Its  prolonged  use  in  cases  which  are  per- 
sistently and  obstinately  constipated  is  not  to  be  generally  advised. 
The  writer  deprecates  the  giving  of  the  water  in  doses  sufficient  to 
cause  exhausting  diarrhea,  his  rule  being  to  give  the  water  in  such 
doses  that  the  patient  has  but  one  unformed,  but  not  watery  movement 
daily.  Smaller  doses  must  be  given  at  home  than  at  the  springs. 
Generally  one  glass  as  hot  as  can  be  sipped  is  to  be  taken  before  break- 
fast. If  no  looseness  of  the  bowels  result,  an  additional  half  dose  is 
to  be  given  at  bedtime,  or  if  necessary,  one-half  hour  before  lunch  as 
well.  If  the  one  morning  dose  is  too  effective,  only  half  the  glass  is  to 
be  taken  in  the  morning  and  the  remaining  half  at  night. 

The  Carlsbad  treatment  should  not  be  given  longer  than  a  month 
at  a  time  without  interruption.  In  those  who  are  weak  and  debilitated 
Vichy  may  be  given  in  similar  doses,  and  of  the  temperature  of  110° 
to  112°.  Vichy  and  Carlsbad  waters  together  with  those  of  Marienbad, 
Franzensbad,  and  Tarasp  are  contra-indicated  in  all  cases  with 
diminished  hydrochloric  acidity. 

Gastritis  with  diminished  acidity  is  best  treated  by  Kissingen 
(Rakoczy  Spring),  Homburg  (Elizabeth  Quelle),  or  Ems.  The  water 
is  to  be  warm  if  the  patient  is  constipated,  hot  if  there  be  diarrhea. 
The  dose  should  be  one-half  to  one  glass  an  hour  before  each  meal. 
The  results  are  exceedingly  good  when  there  is  much  mucus  and 
hydrochloric  acid  is  present,  though  in  a  diminished  amount.  Patients 
without  traces  of  hydrochloric  acid  and  without  much  mucus  are  not 
usually  benefited  by  Kissingen  water,  or  by  the  others  just  mentioned. 

Patients  with  normal  acidity  are,  as  a  rule,  not  benefited  by  medi- 
cinal waters,  unless  the  quantity  of  mucus  is  considerable.  The 
waters  of  Ems,  Homburg,  or  Wiesbaden  (Kochbrunnen)  may  be  then 
recommended. 

There  are  many  medicinal  springs  in  the  United  States  which  would 
rival  in  popularity  those  on  the  continent  if  the  physiological  results 
of  their  use  on  gastric  secretion  were  as  scientifically  studied,  and 
their  respective  indications  in  gastro-intestinal  disorders  as  accurately 
defined. 

Treatment  with  Lavage. — Lavage  is  a  valuable  adjunct  of  treatment 
in  many  cases,  but  it  should  not  be  indiscriminately  advised.  The 
writer's  experience  is  that  lavage  is  employed  far  too  frequently  in 
gastro-iiitestiiial  disorders  and  often  does  more  harm  than  good. 

The  chief  indication  for  lavage  in  gastritis  is  the  -presence  of  mucus 
in  such  excess  that  it  envelops  the  food  masses  and  prevc7its  their  satura- 


CHRONIC  CATARRHAL  GASTRITIS  67 

tion  by  the  digestive  juices.  The  time  has  passed  when  we  wash  every 
stomach  in  whose  contents  small  amounts  of  mucus  are  found.  In 
the  hyperacid  form  we  must  further  remember  that  a  mucous  coating 
of  the  lining  of  the  stomach  is  nature's  protection  against  irritation 
by  food  and  by  gastric  juice  of  heightened  acidity.  It  has  been  even 
suggested  that  the  relief  from  discomfort  that  often  follows  lavage 
with  silver  nitrate  solutions  is  due  rather  to  the  effect  produced  by 
inducing  free  mucus  discharge  that  protects  the  mucous  membrane, 
rather  than  to  its  cleansing  effect.  When  mucus  is  not  present,  there 
seems  to  be  no  reason  for  washing  the  stomach,  especially  as  in  gas- 
tritis food  stagnation  and  fermentation  do  not  occur.  Lavage  in 
impressionable  subjects  may  occasionally  prove  beneficial  as  a  purely 
suggestive  and  psychical  form  of  treatment. 

The  beneficial  effects  of  lavage  are  especially  observed  in  gastritis 
with  a  normal  or  diminished  acidity,  accompanied  by  abundant  mucous 
secretion.  In  achylia  with  the  "dry  form"  of  test  breakfast  the  results 
of  lavage  are  entirely  negative. 

Should  atony  coexist,  lavage  must  be  given  with  some  caution. 
Only  small  quantities  of  water,  never  over  half  a  pint,  should  be  intro- 
duced at  any  one  time,  and  every  effort  should  be  made  to  w^ithdraw 
as  much  of  the  water  as  possible,  so  as  to  leave  the  stomach  compara- 
tively empty.  The  difference  between  the  total  amount  of  water 
introduced  and  the  amount  returned  as  wash-water  should  never 
exceed  10  to  12  ounces. 

Lavage  should  not  be  given  at  a  time  when  the  stomach  contains 
food,  as  the  tube  easily  becomes  blocked,  and  the  amount  of  residual 
water  retained  is  rendered  excessive.  It  is  much  easier  to  pour  water 
in  than  to  siphon  it  out  in  these  cases.  Moreover,  by  lavage  after 
meals  the  patient  is  deprived  unnecessarily  of  his  nourishment.  The 
writer  has  repeatedly  seen  patients  who  w^ash  their  stomachs  after 
each  meal,  because  they  found  that  mucus  was  present,  depriving 
themselves  of  the  benefit  of  their  food,  and  inducing  an  atonic  state 
of  the  stomach  which  aggravates  their  gastric  distress.  Lavage  should 
never  be  employed  oftener  than  once  a  day,  and  the  writer's  preference 
is  in  the  morning  before  breakfast  as  a  part  of  the  morning  toilet.  In 
office  practice  the  best  time  is  late  in  the  forenoon,  at  least  three  and 
one-half  or  four  hours  after  breakfast.  Lavage  on  retiring  is  often 
recommended,  as  it  insures  a  clean  and  empty  state  of  the  stomach 
during  the  night;  but  when  recommended  at  this  time,  it  must  be 
stipulated  that  the  evening  meal  should  be  light,  more  of  a  supper  than 
a  dinner,  and  that  at  least  three  and  one-half  hours  must  elapse  before 
the  stomach  is  cleaned. 

Care  should  be  exercised  in  the  selection  of  the  tube.    Tubes  of  small 


68 


CHRONIC  GASTRITIS 


caliber  with  small  openings,  and  with  rough  edges  to  the  apertures 
should  be  avoided.  A  fairly  large  tube  of  good  caliber  renders  cleansing 
more  effective,  shortens  the  process,  and  is  generally  preferred  by  the 
patient. 

The  simple  lavage  set,  comprising  the  tube,  an  extra  piece  of  rubber 
tubing,  and  a  funnel,  serves  admirably  in  the  great  majority  of  cases. 
^Yhen  it  is  difficult,  however,  to  withdraw  the  water  introduced,  the 
writer  recommends  that  an  aspirating  bulb  be  inserted  midway  between 
the  fuimel  and  the  glass  connection  that  binds  the  extra  rubber  tubing 
to  the  stomach-tube  itself.  Pinching  the  tube  on  the  proximal  side  with 
the  fingers  and  compressing  the  bulb,  and  then  pinching  the  distal 
side  and  relaxing  the  pressure  on  the  bulb,  will  create  a  suction  that 
is  sufficient  to  aspirate  the  stomach  contents. 

Fig.  U 


Stomach-tubes.     A,  proper  tube,  large  smooth  eye,  sufficient  caliber;  B,  improper  tube,  eye  too  small: 
C,  improper  tube,  eye  .sharp  and  small. 

The  writer's  apparatus  for  office  lavage  is  thus  constructed:  A  jar 
of  4  liters'  capacity  is  connected  by  rubber  tubing  around  with  a  pinch 
cork  to  a  glass  T-tube,  to  the  remaining  arms  of  which  are  attached 
the  stomach-tube  and  a  piece  of  rubber  tubing  that  leads  to  a  rece])tacle, 
graduated  uniformly  with  the  jar  that  contains  the  water  to  be  intro- 
duced. An  aspirating  bulb  is  introduced  in  the  exit  tube  near  its  con- 
nection with  the  glass  T-tube,  and  the  proximal  and  distal  portions  of 
the  tube  about  six  inches  from  the  bulb  are  loosely  looi)ed  together. 
The  tube  is  held  by  the  operator  at  the  point  where  the  tube  is  looped. 
Throwing  the  bulb  to  one  or  the  other  side  kinks  it  so  as  to  practically 
form  a  valve. 

By  alternately  compressing  and  relaxing  the  bulb,  and  by  creating 
kinks  as  described  in  one  or  the  other  loops,  aspiration  of  the  stomach 


CHRONIC  CATARRHAL  GASTRITIS 


69 


contents  is  rendered  easy.  By  a  reverse  process  water  may  again  be 
thrown  back  into  the  stomach  with  sufficient  force  to  dislodge  adherent 
mucus,  or  to  clean  the  tube  should  it  become  l)l(x-ked. 


Fig.  12 


Expression  bulb  and  valve.     Flow  from  stomach  blocked.     Compression  of  bulb  forcing  its 
contents  into  the  reception  jar. 


Fig.   13 


Expression  bulb  and  valve.     Outflow  blocked.     Hand  bulb  aspirating  fluid  from  the  stomach. 


70  CHRONIC  GASTRITIS 

ALCOHOLIC    GASTRITIS 

The  alcoholic  form  of  gastritis  is  characterized  by  the  predominance 
of  nausea  and  vomiting  and  by  epigastric  pain  and  tenderness.  These 
sj'mptoms  occur  but  rarely  in  the  non-alcoholic  varieties.  The  impres- 
sion that  we  have  of  gastritis,  as  a  whole,  largely  depends  whether  we 
study  the  disease  in  private  or  in  hospital  practice,  as  in  the  hospital 
cases  we  have  a  large  number  of  alcoholic  patients,  not  only  because 
the  admissions  are  largely  recruited  from  the  laboring  classes,  in  whom 
alcoholic  excesses  are  unfortunately  so  common;  but  also  because  the 
symptoms  of  the  alcoholic  variety  are  more  urgent  than  are  those  of 
the  other  forms,  so  that  the  patients  are  obliged  by  the  necessity  of 
their  ailment  to  apply  for  hospital  treatment.  It  is  probable  in  this 
way  that  w^e  have  come  to  regard  gastritis  as  regularly  accompanied 
by  pain,  nausea,  and  vomiting.  If  we  separate,  however,  those  cases 
in  which  the  alcoholic  habit  is  not  a  factor  in  inducing  the  disease 
from  those  cases  in  whom  it  is  well-marked  and  excessive,  it  will  be 
seen  that  these  symptoms  occur  almost  exclusively  in  the  latter  class 
of  patients. 

Etiology. — It  is  implied  by  the  term  "alcoholic  gastritis"  that  the 
cause  is  due  to  regular  indulgence  in  alcohol,  chiefly  in  a  concentrated 
form.  The  cheaper  varieties  of  whisky,  largely  consumed  by  the 
laboring  classes,  is  decidedly  more  irritating  than  are  the  more  refined 
brands,  which  they  find  too  expensive  to  obtain.  The  difference  in 
personal  reaction  to  alcoholic  irritation  has  previously  been  noted. 
Drinking  on  the  empty  stomach  is  more  irritating  than  a  similar 
quantity  consumed  at  meals. 

Pathology. — The  lesions  of  chronic  gastritis  are  almost  regularly 
present  with  an  increase  in  the  amount  of  interstitial  inflammation, 
more  than  is  usually  seen  in  the  non-alcoholic  forms.  OAving  to  the 
predominance  of  the  interstitial  inflammation,  there  is  a  tendency  for 
the  lesion  to  assume  the  atrophic  form.  This  was  observed  in  50  per 
cent,  of  the  Bellevue  cases. 

In  other  and  rarer  instances  the  examination  of  the  stomach  fails 
to  reveal  a  sufficient  cause  for  distressing  symptoms  that  have  appeared 
during  the  life  of  the  patient.  The  stomach  may  appear  normal  to 
the  eye,  while  on  microscopical  examination  the  lesions  of  catarrhal 
or  interstitial  gastritis  are  so  insignificant  that  it  is  difficult  to  explain 
the  lack  of  proportion  between  the  clinical  symptoms  on  the  one  hand, 
and  the  ])athological  evidences  of  disease  on  the  other. 

Symptoms. — The  symptoms  usually  appear  after  periods  of  excessive 
intemperance,  and  are  relieved  by  the  assumption  of  more  temperate 
habits. 


ALCOHOLIC  GASTRITLS  71 

Nausea  is  an  early  and  fairly  constant  symptom,  appearing  shortly 
after  meals,  and  depending  on  its  intensity  upon  the  quantity  of  food 
that  has  been  eaten.  It  is  less  marked  when  liquids  or  milk  are  taken 
than  upon  a  general  or  mixed  diet.  With  this  nausea  appears  repug- 
nance to  food,  which  is  often  so  marked  that  the  patient  refuses  all 
nourishment,  and  attempts  to  sustain  himself  by  repeated  doses  of 
whisky. 

In  more  severe  cases,  vomiting  appears  after  attempts  at  eating, 
and  consists  of  food  intimately  admixed  with  ropy  masses  of  mucus. 
Watery  or  acid-vomiting  does  not  occur  as  in  ulcer.  The  vomitus  is 
not  usually  offensive,  although  evidences  of  fermentation  may  occa- 
sionally be  present,  especially  if  hydrochloric  acidity  be  diminished. 
The  vomiting  does  not  cease  when  the  stomach  is  empty,  but  attempts 
at  vomiting  continue,  either  as  "dry  retching"  or  resulting  in  the 
raising  of  small  quantities  of  mucus  or  bile. 

In  the  majority  of  cases  there  is  now  added  the  morning  retching, 
which  is  one  of  the  most  characteristic  s\Tiiptoms  of  the  disease;  there 
are  repeated  gaggings  and  retchings  which  raise  but  small  quantities 
of  mucus  or  "slime,"  as  the  patients  describe  it,  or  else  quantities  of 
brackish  fluid,  which  consists  of  the  pharyngeal  and  salivary  secretions 
that  have  been  swallowed  during  the  night.  This  latter  form,  the 
"vomitus  matutinus,"  is  rather  an  indication  of  chronic  pharyngitis 
than  of  gastritis,  but  it  occurs  with  unusual  frequency  in  alcoholic 
patients.  The  morning  nausea  and  retching  are  usually  promptly 
relieved  by  drinking  whisky,  and  the  patient  will  often  find  that  he 
is  unable  to  eat  his  breakfast  imless  it  is  preceded  by  a  dose  of  con- 
centrated alcohol  in  one  form  or  another.  The  taking  of  whisky 
before  breakfast  marks  the  height  of  alcoholic  intemperance.  Relief 
is  often  obtained  by  spraying  the  pharynx  with  a  w^eak  solution  of 
cocaine  (although  this  is  never  to  be  recommended  to  the  patient,  for 
obvious  reasons)  or  by  small  doses  of  anesthesine  placed  upon  the 
tongue  and  slowly  swallowed. 

Pain  is  almost  exclusively  seen  in  the  alcoholic  form,  and  is  usually 
of  a  dull,  aching  character — rarely  sharp  or  lancinating,  quite  different 
from  the  burning,  boring  pain  of  ulcer.  From  this  latter  condition  it 
may  furthermore  be  distinguished  by  its  appearance  during  the  height 
of  digestion  and  not  as  in  ulcer,  during  the  emptying  of  the  stomach; 
it  is  an  "eating  pain"  and  not  a  "hunger  pain,"  occasionally  quite 
intense,  but  more  frequently  described  as  more  distressing  than  unbear- 
able. In  rarer  cases  the  degree  of  pain  is  negligible.  Tenderness  is 
marked  in  the  epigastrium  during  the  acuteness  of  the  attack.  Tender- 
ness on  deep  pressure  is  limited  to  the  gastric  boundaries,  that  elicited 


72  CHRONIC  GASTRITIS 

by  light  pressure  indicating  tenderness  of  the  abdominal  wall  itself, 
may  extend  beyond  the  confines  of  that  organ. 

Alcoholic  gastritis  appears  usually  in  attacks,  following  alcoholic 
excesses  and  lessens  rapidly  with  hospital  care  and  a  reduction  of 
the  exciting  cause.  During  the  stage  of  intermission  the  tenderness 
lessens  and  the  nausea  and  vomiting  disappear  entirely,  but  are  apt 
to  recur  from  time  to  time,  especially  after  dietetic  errors.  These 
symptoms  slowly  but  steadily  become  less  frequent  and  severe  if  the 
patient  changes  his  habits,  or  may  become  again  distressing  after  the 
next  period  of  alcoholic  excess. 

Clinical  History  of  Chronic  Alcoholic  Gastritis. — John  T.,  aged  forty- 
seven  years;  longshoreman;  admitted  March  28,  1909.  For  years  the 
patient  has  been  a  steady  drinker,  taking  whisky  before  breakfast,  two 
or  three  drinks  during  the  day,  and  as  much  beer  as  he  can  afford  to 
buy.  From  time  to  time  he  goes  on  prolonged  sprees,  and  frequently 
has  been  treated  in  the  alcoholic  wards  for  acute  alcoholism.  He  eats 
irregularly,  and  his  food  is  poor. 

Three  years  ago  he  began  to  complain  of  morning  nausea  and  retch- 
ing, raising  only  a  "little  slime"  after  repeated  gagging.  He  could  not 
eat  his  breakfast  until  he  had  taken  his  whisky.  This  morning  "dry 
retching"  was  especially  marked  after  his  sprees,  and  at  these  times 
there  would  be  distress  in  the  epigastrium,  amounting  often  to  a  dull, 
aching  pain,  coming  soon  after  eating,  and  gradually  wearing  away 
after  one  or  two  hours. 

At  the  times  of  excessive  drinking  the  pain  was  both  severe  and 
constant.  He  vomited  but  rarely  except  after  his  sprees,  when  he 
might  go  two  or  three  days  at  a  time  unable  to  retain  anything  on  his 
stomach.  There  had  been  considerable  gas  in  the  stomach  and  belching. 
Two  weeks  before  admission  he  began  to  drink  more  than  usual — his 
morning  retching,  nausea,  and  vomiting  started  anew,  and  he  refused 
all  food,  taking  only  whisky.  He  became  very  nervous  and  imable 
to  sleep,  and  entered  the  hospital  complaining  of  nausea,  vomiting, 
more  or  less  constant  epigastric  pain,  intense  nervousness,  and  weakness. 

Plij/s-iral  Exdmiiiaiioji.  Well  nourished;  looks  alcoholic  rather  than 
ill;  arteries  thickened,  tension  slightly  increased;  heart  normal  in  size 
and  action,  second  aortic  accentuated;  epigastrium  diffusely  tender; 
liver  apparently  normal  in  size;  spleen  not  palpable. 

Urine,  1030;  trace  of  albumin,  hyaline,  graiuilar,  and  a  few  epithelial 
casts. 

Fasfiiif/  fifoninrh:  Fmpty. 

Test  hreakjasi:  40  c.c,  sei)arating  into  layers;  one-third  clear  fluid, 
two-thirds  well-digested  brcadstuft's;  no  mucus;  total  acidity,  65;  free 
hx'drochloric  acid,  .30. 


ALCOHOLIC  GASTRITLH  73 

Diagnosis. — Gastric  Analysis. — Examination  of  the  fasting  stomach 
is  usually  negative,  although  small  amounts  of  swallowed  pharyngeal 
and  salivary  secretions  may  be  found.  Hypersecretion  and  food  stag- 
nation do  not  occur. 

1.  The  test  breakfast  may  be  unchanged  to  any  great  extent  from 
the  normal.  It  is  remarkable  what  good-looking  test  breakfasts  may 
be  found  in  alcoholic  gastritis  with  morning  vomiting,  and  this  apparent 
good  digestion  may  even  coexist  with  a  clinical  liistory  of  prolonged 
and  severe  outbreaks  of  the  disorder. 

2.  In  other  cases  the  test  breakfast  is  increased  in  amount,  poorly 
chymified,  and  admixed  with  a  large  quantity  of  thin  mucus.  The 
acidity  is  reduced,  although  traces  of  free  hydrochloric  acid  are 
present. 

Estimation  of  pepsin  acidity  by  the  Hammerschlag  or  Metts  method 
shows  a  reduction  of  peptic  power.  Proteid  reactions  are  diminished. 
The  starch  digestion  is  usually  carried  to  full  completion.  Occult 
blood  does  not  occur.  This  tendency  to  the  reduction  of  hydrochloric- 
acid  secretion  occurs  more  frequently  in  the  alcoholic  than  in  the 
non-alcoholic  varieties  It  is  the  writer's  experience  that  a  previous 
hyperacidity  does  not  occur. 

In  long-continued  cases  we  may  find  achylia,  the  test  breakfast 
being  either  the  "dry"  or  the  "wet"  form.  In  the  dry  form  the  test 
breakfast  consists  of  a  small  amount  of  dryish,  undigested  bread 
fragments,  as  if  bread  had  been  partially  masticated  and  then  rejected. 
Mucus  is  present  in  small  quantities,  enveloping  and  infiltrating  the 
food  fragments.  Hydrochloric  acid  is  absent  both  in  the  free  and 
combined  states.  Pepsin  reactions  are  greatly  reduced.  This  form 
of  gastric  analysis  occurs  but  rarely  in  alcoholic  gastritis.  The  following 
example  may  be  given: 

Mrs.  X,  aged  thirty-two  years,  was  well  until  1897,  when  her  hus- 
band suddenly  died.  She  returned  home  to  live  with  her  mother,  "who 
nagged  at  her,"  and  she  became  so  blue  and  depressed  that  she  drank 
brandy  continually  "to  cheer  up." 

In  1904  she  married  and  was  again  happy,  although  she  continued 
to  drink  "to  be  sociable."  She  soon  began  to  complain  of  frequent 
attacks  of  vomiting,  and  her  stomach  pained  her  after  her  meals. 
These  symptoms  have  continued  with  greater  or  less  severity  ever 
since — a  period  of  nearly  three  years. 

For  the  past  four  weeks  she  has  awakened  with  nausea  and  "dry 
retching,"  and  cannot  eat  until  she  drinks  brandy,  although  she 
knows  that  if  she  drinks  at  this  time  she  will  suffer  from  nausea  and 
vomiting  throughout  the  day. 

Physical  examination  showed  no  evidence  of  organic  disease.    Liver 


74  CHRONIC  GASTRITIS 

and  spleen  apparently  normal.  Examination  is  difficult  because  of 
obesity. 

The  test  breakfast  brought  10  c.c.  of  dryish,  squeezed-out  bread- 
stuffs  without  admixture  of  mucus.  Total  acidity,  G;  free  hydrochloric 
acid,  negative.  The  quantity  was  insufficient  for  estimations  of  ferment 
activity. 

Wet  achylia,  or  the  form  characterized  by  the  overproduction  of 
mucus,  is  more  common  than  the  preceding  types.  The  test  break- 
fast is  more  abundant,  usually  from  100  to  150  c.c.  in  quantity,  and 
consists  of  undigested  breadstuffs  floating  in  this  liquid  mucus.  Hydro- 
chloric acid  is  absent.  Peptic  power  is  greatly  diminished.  Lactic 
acid  does  not  occur. 

Achylia  in  one  or  the  other  form  regularly  accompanies  alcoholic  gas- 
tritis when  cirrhosis  of  the  liver  is  present.  In  14  consecutive  cases  of 
alcoholic  gastritis,  complicated  by  cirrhosis  of  the  liver,  this  form  of 
achylia  was  found  in  every  instance.  This  is  interesting,  as  it  suggests 
that  the  achylia  is  the  cause  for  the  diarrhea  so  frequently  observed 
in  cirrhosis,  instead  of  portal  congestion  as  usually  described,  and  that 
it  is  to  be  treated  by  entirel}^  different  methods  and  diets. 

Prognosis. — The  prognosis  of  alcoholic  gastritis  depends  upon 
whether  the  patients  are  able  to  control  their  habits.  If  they  will 
stop  drinking,  lead  temperate  and  rational  lives,  a  clinical  cure  will 
result,  although  it  is  not  to  be  expected  that  the  pathological  changes 
in  the  stomach  will  show  much  if  any  improvement. 

Treatment. — During  the  acute  attack  all  alcohol  should  at  once  be 
discontinued.  Should  it  so  happen  that  the  patient  is  on  the  verge  of 
delirium  tremens,  bromides  and  chloral  are  to  be  given,  preferably  by 
rectum  and  5j  doses  of  paraklehyde,  two  or  even  three  times  a  day, 
are  of  service  in  allaying  the  restlessness.  The  unpleasant  taste  may 
be  disguised  as  in  the  following  prescription : 

I^ — Paraldehyde 5j 

Glycerin 3iij 

Spirit  vini  rect.  5j 

Tinct.  cardamom,  comp 3j 

01.  aurantii, 

01.  cinnamom iia  TTlj 

Elixir  aurantii ad  5iv — M. 

Sig. — Tablcspoonful  in  water  every  three  hours. 

The  occurrence  of  cerebral  symjitoms  is  not  a  sufficient  reason  for 
again  resorting  to  the  use  of  alcohol.  Hot  fermentations  to  the  epiga.s- 
trium  are  usually  of  the  greatest  comfort  in  relieving  the  soreness  and 
distress.    For  a  few  hours  the  stomach  should  be  given  rest  from  food. 


ALCOHOLIC  GASTRITIS  75 

but  abstinence  should  not  be  continued  longer  than  ten  to  twelve  hours. 
Liquid  and  semisolid  food  should  then  be  given  at  intervals  of  two  or 
three  hours.  The  actual  choice  of  food  is  quite  unimportant;  any  simple 
semi-invalid  form  of  nourishment  will  answer,  as  it  is  more  desirable 
to  see  that  nourishment  is  taken  than  to  be  overparticular.  After 
the  acuteness  of  the  attack  has  subsided,  more  solid  food  can  be  given, 
and  should  preferably  be  rather  highly  seasoned. 

Benefit  often  follow\s  a  stimulating  carminative  just  before  food  is 
taken.  Capsicum  and  nux  vomica  and  digitalis  are  important  adjuncts 
of  treatment,  and  may  be  given  as  in  the  following  prescription: 

I^ — Tinct.  capsici Tlliij 

Tinct.  digitalis TTlv 

Tinct.  nucis  vomic TTlx 

Tinct.  cardamom,  comp ad  3j — M. 

Sig. — Such  a  dose  in  water  before  eating. 

The  following  is  often  of  service  during  the  acute  stages : 

I^ — ^Tinct.  capsici 3ij 

Sodii  bromid 3iij 

Elixir  lupulini ad  giv — M. 

Sig. — Dessertspoonful  in  water  every  two  or  three  hours. 

The  bowels  should  be  freely  opened,  preferably  by  magnesium 
sulphate.  After  the  attack  subsides  the  subsequent  treatment  is  that  of 
the  non-alcoholic  forms  of  gastric  catarrh.  Alcohol  must  be  absolutely 
interdicted. 


CHAPTER   III 
CIRRHOSIS  OF  THE  STOMACH   (LINITIS  PLASTICA) 

LiNiTis  plastica  or  cirrhosis  of  the  stomach  is  a  term  used  to  desig- 
nate a  rare  disease  of  the  stomach  characterized  by  a  circumscribed  or 
diffuse  increase  of  connective  tissue,  chiefly  in  the  submucosa,  and 
to  a  lesser  degree  in  the  other  coats,  causing  a  marked  thickening  in 
its  walls.  A  number  of  synonyms  for  this  condition  are  found  in 
Hterature;  chronic  interstitial  gastritis,  gastric  fibrosis,  sclerosis  of  the 
stomach,  fibroid  induration,  hypertrophic  stenosing  gastritis,  hyper- 
trophic pyloric  stenosis,  submucosa  sclerosis  with  chronic  gastritis,  and 
callous  retroperitonitis  are  among  those  most  frequently  employed. 
The  terms  "linitis  plastica,"  originally  used  by  Brinton  in  his  descrip- 
tion of  the  disease,  and  "cirrhosis  of  the  stomach"  are  the  ones  in 
most  common  use. 

Nature  and  Pathogenesis. — There  are  many  theories  adduced  to 
explain  this  peculiar  condition  of  gastric  fibrosis,  few  of  them,  however, 
are  substantiated  by  facts.  Among  the  various  hypotheses  advanced, 
only  two,  opposed  to  each  other,  are  worthy  of  discussion:  one  that 
linitis  pla.stica  is  a  special  lesion  of  indefinite  nature  and  cause;  the 
other  that  it  is  a  variety  of  scirrhous  cancer.  The  most  important 
problem  today  is  the  distinction,  if  any,  between  linitis  plastica  and 
cancer. 

Before  pathology  attained  its  present  stage  of  development,  many 
cases  were  reported  as  benign  fibrosis  that  would  not  bear  muster 
under  present  requirements.  Incomplete  and  hasty  examinations  in 
many  cases  have  failed  to  reveal  epithelial  nests  that  probably  would 
have  been  found  had  the  search  been  sufficiently  painstaking.  Even 
microscopic  examination,  that  seems  sufficiently  thorough,  may  fail 
at  first  to  detect  evidences  of  malignancy.  More  careful  examination 
may  finally  detect  cancer  elements  tliat  were  overlooked  in  the  first 
examination. 

Thus  Curtis'  exhibited  the  stomach,  ileum,  and  colon  of  a  patient 
as  an  example  of  linitis  ])lasti('a.  Discussion  arising  as  to  the  com])lctc- 
ncss  of  tiiis  examination,  lie  made  a  further  search  and  found  a  small 

'  Arc-yiiv.  de  niwi.  expt-r.,  190S;  also  Bull,  ct  iric'iii.  dc  la  Soc.  anal.,  1909,  No.  1, 
p.  14;  also  Bull,  ot  mem.  Soc.  anal,  do  Paris,  1909,  No.  3. 


NATURE  AND  PATHOGENESIS 


77 


area  which  was  distinctly  carcinomatous.  Although  the  argument  is 
not  conclusive,  it  may  be  said  that  in  a  number  of  instances  what 
seemed  to  be  indubitable  fibrosis  of  benign  character  at  operation 
presented  later  clinical  and  pathological  proof  of  malignancy.  Woolsey, 
for  example,  reported  a  case  of  supposed  linitis  plastica,  for  which  a 
gastro-enterostomy  was  done,  with  apparent  restoration  to  health. 
Within  two  years,  however,  the  patient  died  of  cancer.  It  may  be 
urged  that  in  such  cases  carcinomatous  degeneration  occurred  as  a 
late  event  analogous  to  the  development  of  malignancy  at  the  base  of 
a  chronic  gastric  ulcer. 


Fig.   14 


Linitis  plastica. 


Those  who  assert  that  gastric  cirrhosis  is  identical  with  a  form  of 
scirrhous  cancer,  support  their  view  by  the  presence  of  analogous 
lesions  in  other  parts  of  the  alimentary  tract,  in  the  ileum,  colon, 
rectum,  peritoneum,  and  retroperitoneal  tissues.  These  accessory 
lesions,  considered  by  them  to  be  due  to  a  retrograde  lymphatic  involve- 
ment, suggest  a  cancer  origin  even  though  no  cancer  nests  are  actually 
discovered  in  the  wall  of  the  stomach  itself.  On  the  other  hand,  so- 
called  cancer  elements  may  be  simulated  by  distorted  glandular  tubules 
infolded  by  dense  masses  of  connecting  tissue  assuming  somewhat 
an  adenomatous  structure,  or  by  cells  which  result  from  proliferation 
of  the  endothelium  lining  the  normal  lymph  spaces.  It  has  been 
thought  by  some  that  the  embryonic  nature  of  the  growth  has  been 


78  CIRRHOSIS  OF  THE  STOMACH 

suggestive  of  sarcoma.  It  is  this  uncertainty  that  makes  it  difficult 
to  state  without  reservation  that  a  true  fibrosis  of  the  stomach  may 
occur  without  cancer.  The  existence  of  such  a  primary  fibrosis  cannot, 
at  the  present  time,  be  denied,  but  it  must  be  conceded  that  such  a 
lesion  is  exceedingly  rare,  and  that  the  great  majority  of  cases  reported 
as  linitis  plastica  are  really  examples  of  cancer,  the  difference  being 
that  in  the  one  instance  cancer  elements  are  found  on  microscopic 
examination,  while  in  the  other  these  elements  are  not  found,  either 
because  they  are  overlooked  or  because  they  are  not  there. 

Etiology. — The  disease  is  one  of  adult  life.  Of  61  cases  reported  by 
Lyle  the  ages  are  grouped  as  follows: 

Between  20  and  30  years 6  cases 

Between  30  and  40  years 13  cases 

Between  40  and  50  years 17  cases 

Between  50  and  60  years 11  cases 

Between  60  and  70  years 12  cases 

Between  70  and  80  years 2  cases 

Men  are  more  frequently  affected  than  women.  In  Lyle's  cases 
there  were  41  men  and  22  women. 

As  to  its  actual  cause  we  are  entirely  in  the  dark.  Many  writers 
claim  that  the  disease  is  most  common  in  tuberculous  patients;  other 
observers  have  attempted  to  refer  the  ailment  to  chronic  venous  con- 
gestion caused  by  arteriosclerosis  and  cardiac  insufficiency.  Both  these 
etiological  theories  lack  verification. 

Alcoholism  has  been  adduced  as  an  etiological  factor,  but  there  seems 
to  be  no  conclusive  evidence  that  it  stands  in  any  causal  relation  to 
the  disease.  Syphilis  may  produce  a  connective-tissue  proliferation 
in  the  wall  of  the  stomach,  which  is  with  great  difficulty  distinguishable, 
microscopically,  from  the  non-specific  fibrosis.  How  many  cases 
reported  as  examples  of  the  latter  affection  may  in  reality  have  been 
specific  is  naturally  a  matter  of  pure  conjecture.  The  localized  form 
of  hypertrophic  pyloric  stenosis  of  the  adult  (quite  different  in  its 
pathology  from  that  of  the  infant)  may,  according  to  some  observers 
(Hemmeker,  Boas,  etc.),  be  not  uncommonly  caused  by  a  chronic 
gastritis.    It  is  exceedingly  doubtful  if  this  opinion  be  correct. 

A  few  well-recorded  cases  have  shown  that  the  fibrosis  had  evidently 
started  from  the  base  of  a  chronic  ulcer,  the  process  practically  resulting 
in  a  keloid. 

It  is  an  undisputed  fact  that  ulcers,  even  though  they  be  of  small 
size,  may  result  in  the  spreading  formation  of  cicatricial  tissue  extending 
through  the  various  coats  of  the  stomach.  Should  the  ulcer  heal,  it  is 
naturally  difficult  to  prove  the  etiological  factor  in  such  a  sclerotic 


PATHOLOGY  79 

process.  When  the  ulcer  remains  open,  the  relationship  between  the 
ulcer  and  the  spreading  deposit  of  connective  tissue  is  more  obvious. 
Illustrations  showing  the  relationship  of  ulcer  to  a  localized  fibrosis 
will  be  seen  under  the  Section  on  Pathology.  Multiple  small  ulcers 
have  been  supposed  by  some  to  be  the  cause  for  the  widespread  dis- 
tribution of  the  lesion  in  some  instances. 

Pathology. — The  disease  occurs  in  a  localized  and  in  a  diffused  form. 

Localized  Fibrosis. — In  this  form  there  occurs  a  connective-tissue 
thickening  from  a  localized  induration  in  some  part  of  the  stomach 
wall.  The  favorite  seat  of  selection  is  the  pyloric  portion,  the  new 
connective  tissue  often  encircling  and  narrowing  the  canal.  With  but 
rare  exceptions  the  infiltration  ceases  abruptly  at  the  pylorus,  and  does 
not  invade  the  duodenal  tissues.  In  some  cases  the  callous  thicken- 
ing is  the  direct  result  of  an  old  ulcer  situated  in  the  pylorus.  In 
other  instances  the  ulcer  may  be  situated  at  some  distance  from  the 
pyloric  canal,  but  from  it,  extending  toward  the  pylorus,  is  an  area 
of  fibrosis,  increasing  in  thickness  as  it  approaches  the  orifice. 


Fig.  15 

Linitis  Plastica: — No  evidence  of  ulcer  or  carcinoma  after 
serial  sections  were  repeatedly  examined.  The  block  shows  the 
actual  size  of  the  thickening.  Note  the  abrupt  change  from  the 
thick  wall  of  the  stomach  to  the  thin  wall  of  the  duodenum. 
The  muscular  coat  can  he  distinguished  from  the  thin  peritoneal 
coat  and  the  greatly  thickened  submucosa.  (From  Bloodgood's 
collection  of  specimens  at  the  Surgical  Pathological  Laboratory 
of  the  Johns  Hopkins  Hospital.) 


In  other  instances  we  have  the  same  fibrosis  of  the  pyloric  end  of 
the  stomach,  even  to  the  point  of  extreme  stenosis,  without  any  evi- 
dence whatever  of  the  previous  existence  of  an  ulcer.  Whether  an 
ulcer  has  previously  existed  or  not  is  a  matter  of  pure  conjecture. 

In  the  localized  form  with  the  lesion  concentrated  at  the  pylorus  the 
tendency  would  naturally  be  for  the  stomach  gradually  to  dilate.  In 
some  instances  such  an  enlargement  of  the  stomach  actually  does  occur, 
so  that  the 'gross  appearance  of  the  stomach  is  that  ordinarily  observed 
in  callous  thickening  of  the  pyloric  canal  from  cicatrization  of  an  old 
ulcer.  It  is  probable  that  many  recorded  instances  of  supposed  local- 
ized fibrosis  in  the  neighborhood  of  the  pylorus  are  in  reality  examples 
of  this  latter  condition  of  cicatrized  ulcer.  In  the  majority  of  cases 
of  localized  fibrosis  the  stomach  is  unchanged  in  size.  It  may  even  be 
contracted. 

The  localized  form  has  been  described  by  Boas  under  the  terms 
chronic  hypertrophic  pyloric  stenosis  and  chronic  stenosing  gastritis. 


Fig.   16 


Gastric  ulcer  on  the  lesser  curvature  some  distance  from  the  pylorus  with  circumscribed  linitis 
extending  from  the  ulcer  to  the  pylorus.  (From  Bloodgood's  collection  of  specimens  in  the  Sur- 
gical Pathological  Laboratory  of  the  Johns  Hopkins  Hospital.) 


Fig.    17 


Fig.   18 


Chronic  sclerosing  gastriti.-i  due  to  iil<cr  al  ;i 
distance  from  the  pylorus,  causing  stenosis.  Illus- 
tration shows  the  pyloric  end  of  the  stomach 
turned  inside  out,  so  that  the  mucous  membrane 
appears  on  the  outside.  The  ulcer  is  shown  clearly 
at  A.  The  n  irrowed  pylorus  is  seen  iit  B.  (From 
Bloodgood's  collection  of  specimens  in  (he  Surgical 
Pathological  Laboratory  of  the  Johns  Hopkins 
Hospital.) 


Section  tlirough  pylorus,  sliowing  con- 
nective -  ti.ssue  tliickcning  and  muscular 
hypertrophy  of  thewall.  (From Bloodgood's 
collect  ion  of  specimens  in  theSurgical  Patho- 
logical Laboratory  of  the  Johns  Hopkins 
Hospital.) 


PATHOLOGY  81 

Diffuse  Form. — In  tlio  seneralized  form  the  fi})r<)sis  induration  is  more 
diffusely  distril)uted.  The  stomaeh  is  usually  much  contracted,  often 
being  likened  in  size  to  that  of  the  normal  colon.  In  Jacobi's  case  the 
lumen  of  the  stomach  was  that  of  the  small  intestine.  In  Lv'le's  patient 
the  stomach  was  spherical  and  of  the  size  of  a  goose  egg.  In  rarer 
exceptions  the  stomach  may  be  normal  or  even  increased  in  size.  In 
the  writer's  case  there  must  have  been  considerable  dilatation  because 
the  volume  of  the  vomited  matters  often  exceeded  a  quart.  Such 
instances  are,  however,  quite  rare. 

The  serous  coat  is  thickened  and  has  a  dull  white,  opaque  appear- 
ance, instead  of  being  clear  and  shining. 

The  gastrohepatic  and  gastrocolic  omenta  usually  show  thickenings, 
contractions,  and  opacities,  and  the  same  appearance  may  be  noted  in 
the  peritoneum  of  the  ileum,  colon,  and  along  the  course  of  the  rectum. 
Dense  areas  of  infiltration  may  be  felt  in  the  retroperitoneal  tissues, 
the  so-called  retroperitoneal  callous  of  Hanot.  Lymph  exudate  may 
appear  on  the  intestinal  coils;  there  may  be  fibrous  adhesions.  Ascites 
is  not  uncommon.  Cirrhosis  of  the  liver  may  coexist.  The  stomach 
affords  considerable  resistance  to  the  passage  of  the  knife  through  its 
walls,  and  often  gives  rise  to  a  creaking  sound  like  cartilage  when  cut. 
When  opened  the  organ  does  not  collapse.  The  cavity  of  the  stomach 
is  often  extraordinarily  small,  so  that  in  the  extreme  degrees  of  con- 
traction the  organ  may  be  able  to  contain  only  two  or  three  ounces  of 
fluid. 

The  lesion  consists  in  the  deposit  of  dense  connective  tissue  in  the 
walls  of  the  stomach,  the  submucous  coat  being  most  extensively 
involved,  the  muscular  and  outer  coats  to  a  less  degree.  According  to 
Brinton  the  submucosa  is  ten  to  twenty  times  its  normal  thickness,  the 
serosa  and  subserosa  seven  to  ten  times,  the  muscular,  five  to  eight 
times,  and  the  mucosa,  two  or  three  times.  The  total  thickness  of  the 
wall  may  be  from  one-half  to  one  inch.  Despite  the  infiltration  the 
layers  remain  quite  distinct  from  each  other,  and  there  is  often  a 
marked  contrast  between  a  fairly  healthy  looking  mucous  membrane 
and  the  enormous  thickening  of  the  remainder  of  the  gastric  wall.  The 
thickening  is  rarely  uniform.  It  is  usually  more  marked  at  the  pj'loric 
end,  and  may  be  absent  at  the  cardia.  The  mucous  membrane  may 
appear  normal,  or  it  may  be  mammillated.  In  other  instances  it  is 
thinned  and  atrophic. 

The  pyloric  canal  is  usually  densely  infiltrated,  resulting  in  stenosis 
to  a  greater  or  a  less  degree.  In  some  instances  the  orifice  may  be 
apparently  patent,  though  from  the  stiffening  of  its  walls  the  orifice 
can  neither  contract  nor  dilate,  forming  thus  a  rigid  opening  which 
practically  has  the  same  effect  as  a  stenosis  in  affording  resistance  to 
6 


82  CIRRHOSIS  OF  THE  STOMACH 

the  passage  of  chyme  from  the  stomach  into  the  duodenum,  and  also 
allows  of  a  duodenal  regurgitation. 

Microscopic  Examination. — The  mucous  membrane  may  be  normal, 
although  usually  evidences  of  catarrhal  gastritis  are  present,  with  a 
well-marked,  small-celled  infiltration  between  the  tubules.  The 
presence  of  the  infiltrating  connective  tissue  may  cause  constrictions, 
cystic  dilatations,  and  other  abnormalities  of  the  gastric  tubules.  In 
rarer  instances  there  may  be  atrophy  of  the  tubules  and  their  replace- 
ment by  connective  tissue,  so  that  the  glandular  elements  completely 
disappear.^ 

The  submucosa  and  outer  coats  are  permeated  by  dense  connective 
tissue,  uniformly  or  in  bands,  as  has  been  above  described.  The 
muscular  fibers  may  undergo  atrophy,  or  in  cases  of  long  standing, 
hypertrophy  of  the  muscularis  may  be  observed. 

Endarteritis  of  the  nutrient  vessels  is  commonly  observed,  although 
it  is  not  an  essential  part  of  the  lesion.  The  perigastric  lymphatic 
glands  are  usually  enlarged  and  show  the  lesions  of  chronic  fibrosis.  In 
other  instances  there  may  be  an  increase  of  cellular  elements  suggesting 
malignant  involvement. 

Through  the  submucous  and  muscular  coats  are  occasionally  found 
epithelioid  nests.  It  is  often  impossible  to  say  whether  these  are 
really  epithelial  in  character  and  therefore  carcinomatous,  or  due  to 
proliferation  of  previously  existing  epithelial  cells  lining  the  lymph 
channels,  which  normally  exist  in  these  situations. 

The  pathology  of  the  associated  peritoneal  and  intestinal  lesions 
and  of  the  retroperitoneal  callosities  is  that  of  the  stomach  wall.  It 
is  unknown  whether  these  accessory  lesions  are  concomitant  with  that 
of  the  fibrosis  formation  in  the  stomach,  or  whether  they  represent,  as 
some  believe,  a  retrograde  lymphatic  involvement  suggestive  of  a 
certain  degree  of  malignancy. 

Symptoms.  Localized  Form. — When  the  lesion  is  concentrated  at 
the  i)ylorus,  the  symptoms  are  practically  those  of  pyloric  stenosis. 
The  onset  is  ordinarily  insidious  and  without  characteristic  symptoms. 
There  is  usually  distress  in  the  epigastrium  at  the  height  of  digestion, 
most  frequently  occurring  one  or  two  hours  after  eating,  of  a  dull 
character,  or  else  sharp  and  colicky.  Tenderness  in  the  epigastrium 
at  this  time  may  be  elicited.  There  may  be  gaseous  eructations,  or 
the  raising  of  acid  fluid  so  characteristic  of  closure  lesions  of  the 
pyloric  canal. 

As  the  disease  progresses  the  sym])t()nis  of  i)yl()ric  stenosis  become 

1  See  Nothnagel,  Deutsch.  Arcli.  f.  klin.  Med.,  1879,  Ikl.  xxiv,  352;  and  Henry 
Osier,  Amer.  .Jour.  Med.  Sci.,  1886,  xc,  486. 


SYMPTOMS  83 

more  and  more  marked,  the  vomiting  becomes  a  more  serious  feature, 
and  interferes  with  the  proper  nutrition  of  the  patient.  The  vomiting 
is  usually  provoked  by  the  taking  of  more  than  a  limited  amount  of 
food.  The  vomited  matters  consist  either  of  food  that  has  been  recently 
taken,  or  they  may  be  abundant,  foul,  and  represent  the  food  remains 
that  have  collected  in  the  stomach  as  the  accumulation  of  several 
meals.  The  latter  type  is  characteristic  of  pyloric  stenosis,  the  former 
that  of  a  stomach  intolerant  of  the  quantity  rather  than  the  quality 
of  food.  The  distress  does  not  occur  at  any  typical  time  relative  to 
the  hour  of  meals.  Occult  blood  is  not  detected  either  in  the  gastric 
contents  or  in  the  stools. 

As  time  goes  on,  the  increasing  inanition  becomes  more  noticeable, 
and  the  subsequent  course,  if  not  interrupted  by  appropriate  treat- 
ment, is  one  of  progressive  weakness. 

Gastric  Analysis. — The  fasting  stomach  is  rarely  empty.  In  the 
early  stages  small  quantities  of  fluid  (20  to  40  c.c),  giving  reaction  for 
free  hydrochloric  acid,  are  withdrawn.  In  the  later  stages  the  fasting 
stomach  contains  not  only  this  acid  fluid,  but  also  food  remains  of 
previous  meals  in  greater  or  less  quantities. 

Test  breakfast  usually  shows  at  first  the  characteristics  of  an  alimen- 
tary hypersecretion,  the  withdrawn  contents  separate  into  two  layers, 
the  upper  layer  of  clear  fluid  being  more  than  twice  the  depth  of  the 
underlying  layer  of  well-digested  breadstuffs.  The  acidity  is  usually 
normal  or  slightly  excessive.  Sarcinse  may  be  present.  The  above 
gastric  analyses  are  practically  those  of  any  form  of  benign  organic 
pyloric  stenosis,  and  do  not  differentiate  the  disease  under  discussion 
from  pyloric  stenosis  of  a  similar  degree  due  to  the  cicatrization  of  a 
pyloric  ulcer. 

In  other  instances,  while  the  same  evidences  of  a  motor  disturbance 
of  the  pylorus  are  evident,  as  shown  by  the  finding  of  fluid  or  food 
remains,  but  the  acidity  of  the  gastric  contents  is  quite  different.  The 
amount  of  hydrochloric  acid  progressively  decreases  and  lactic  acid 
becomes  present,  together  with  smaller  amounts  of  various  volatile 
organic  acids.  The  test  breakfast  is  offensive,  as  are  the  vomited 
matters.  Large  rod-shaped  bacilli  resembling  the  Oppler-Boas  form 
of  lactic-acid  organisms  are  present. 

It  is  this  type  of  gastric  analysis  that  was  present  in  Boas'  cases,^ 
and  so  closely  resemble  cancer  of  the  pylorus  that  a  differential  diagnosis 
is  quite  impossible. 

This  clinical  type  is  quite  rare.  No  case  that  conforms  exactly  with 
Boas'  description  has  come  under  the  writer's  observation,  although 

1  Arch.  f.  Verdauungskrankheiten,  1898,  iv,  47. 


84  CIRRHOSIS  OF  THE  STOMACH 

instances  of  malignant  disease  of  the  pylorus  have  been  frequent  enough 
and  have  given  the  same  clinical  history.  It  is  possible  that  Boas' 
cases  may  have  all  been  malignant. 

Generalized  Form. — In  a  few  instances  the  disease  has  run  a  latent 
course  for  a  long  period  of  time,  as  the  condition  has  been  found  quite 
extensively  developed  in  cases  of  death  from  other  causes,  without 
there  having  been  any  complaint  whatever  of  previous  gastric  distress. 
In  Viti's  case  death  resulted  from  arteriosclerosis,  without  gastric 
symptoms;  the  stomach  was  small  and  thick- walled,  but  without 
stenosis  of  the  pylorus. 

As  a  rule,  however,  gastric  symptoms  appear  early  in  the  disease 
and  run  a  progressive  course,  terminating  in  death  unless  the  condition 
be  surgically  relieved.  Sudden  onset  of  symptoms  is  somewhat  less 
usual. 

Pain  or  distress  is .  one  of  the  early  symptoms,  varying  greatly  in 
different  cases  both  in  intensity  and  in  the  time  at  which  it  appears 
in  relation  to  the  taking  of  food.  Generally  distress  begins  as  soon 
after  the  meal,  in  proportion  to  the  quantity  rather  than  to  the  quality 
of  what  is  eaten,  and  persists  until  the  stomach  partially  empties 
itself  either  normally  through  the  pylorus,  or  by  the  induction  of 
vomiting.  At  first  the  patient  can  keep  himself  quite  comfortable 
by  reducing  the  quantity  of  food  at  each  meal,  but  later  the  pain 
becomes  more  and  more  severe,  and  may  appear  after  even  ver}-  small 
quantities  of  nourishment. 

Vomiting  sets  in  with  pain;  at  first  only  occasionally,  but  gradually 
it  becomes  more  frequent,  so  that  the  patient  will  vomit  part  at  least 
of  everything  he  eats.  The  vomiting  is  characteristic  of  a  small  con- 
tracted, intolerant  stomach  that  can  hold  only  a  certain  quantity  of 
food,  rather  than  that  due  to  pyloric  stenosis  with  food  retention. 

In  rarer  instances  the  vomited  matters  are  profuse,  watery,  and  ill- 
smelling  from  the  presence  of  organic  acids,  evidently  the  result  of 
pyloric  stenosis  with  food  retention.  This  was  the  type  of  vomited 
matter  in  the  case  of  the  writer's,  soon  to  be  described. 

Ilematemesis  and  melena  have  been  described,  but  arc  so  rare  that 
their  occurrence  should  suggest  malignancy  rather  than  an  infiannna- 
tory  fibrosis  of  the  stomach.  There  are  at  this  time  ])rogressive  anemia 
and  emaciation,  quite  indistinguishable  in  character  and  degree  from 
the  similar  cachexia  observed  in  cancer.  The  \\tii\  powers  finally 
diminish  to  the  point  of  fatal  asthenia.  The  final  picture  may  be  that 
of  pernicious  anemia,  as  in  the  case  rejxjrted  b>-  Xothnagel  and  Henry 
Osier,'  in  which  marked  atrophy  of  the  gastric  tubules  was  found, 
together  with  the  characteristic  lesions  of  benign  gastric  sclerosis. 

*  American  Journal  of  the  Medical  Sciences,  1886,  xc,  498. 


DIAGNOSIS  85 

Gastric  ANALYSES.^Ga.stric  analyses  are  practically  those  of 
cancer.  In  the  early  stages  of  the  disease  the  gastric  analyses  do  not 
show  any  departure  from  the  normal.  When,  however,  the  disorder 
is  well  advanced,  there  is  a  tendency  fpr  hydrochloric  acid  to  diminish 
and  finally  disappear.  With  its  disappearance  there  occurs  the  growth 
of  Oppler-Boas  bacilli  and  the  formation  of  lactic  acid.  The  examina- 
tion of  the  fasting  stomach  may  be  normal,  or  may  show  a  moderate 
degree  of  food  stasis.  Excessive  amounts  of  fasting  food  remains  are 
not  ordinarily  withdrawn  at  such  an  examination.  Blood,  either  visible 
or  occult,  should  not  be  present  in  either  the  fasting  contents  or  in  the 
test  breakfast. 

If  it  can  be  determined  that  the  stomach  will  hold  onl}^  a  small 
amount  of  liquid,  sometimes  only  a  few  ounces,  the  diagnosis  will  be 
supported. 

Diagnosis. — Physical  Examination. — During  the  earlier  stages  there 
are  no  characteristic  physical  signs.  There  may  be  a  slight  and  diffuse 
tenderness  in  the  epigastrium,  more  marked  after  the  patient  has 
eaten.  It  is  only  when  sufficient  thickening  of  the  stomach  wall  occurs 
that  resistance  becomes  appreciable,  and  finally  assumes  the  definite 
character  of  a  palpable  tumor. 

In  the  localized  form  the  growth  is  over  the  site  of  the  pylorus,  and 
is  quite  indistinguishable  from  the  mass  found  either  with  callous 
thickening  of  the  pylorus  from  ulcer  or  with  cancer.  Adhesions, 
however,  are  less  liable  to  occur  than  in  these  latter  conditions. 

In  the  generalized  form  the  tumor  becomes  palpable,  usually  under 
the  left  costal  arch,  or  lying  obliquely  downward  and  to  the  right  in 
the  epigastric  area.  It  may  be  round  or  sausage-shaped,  firm  and 
smooth,  fairly  movable,  and  but  slightly  tender.  Percussion  over  the 
tumor  is  never  dull,  but  of  a  moderately  resonant  quality.  It  would, 
however,  be  the  act  of  a  bold,  inexperienced  observer  to  attempt  to 
differentiate  such  a  growth  from  cancer. 

The  size  of  the  stomach  is  determined  with  extreme  difficulty,  owing 
to  the  resistance  its  walls  afford  to  artificial  dilatation.  In  any  sus- 
pected case  dilatation  by  the  usual  methods  must  be  gradually  and 
cautiously  employed,  as  this  method  of  examination  may  occasion 
exquisite  pain.  Usually  all  that  can  be  said  is  that  the  stomach  is  not 
enlarged — how  much  smaller  it  is  than  normal  is  a  matter  of  surmise, 
except  by  the  .r-rays,  by  which  examination  much  valuable  informa- 
tion can  be  obtained.  In  very  rare  cases  the  stomach  can  be  made 
out  enlarged  in  size,  as  in  Nauwerk's  patient,  whose  stomach  filled 
two-thirds  of  the  abdominal  cavity. 

Additional  physical  signs  are  afforded  by  the  presence  of  ascites,  by 
irregular  fibrous  thickenings  along  the  course  of  the  ileum,  colon,  and 


86  CIRRHOSIS  OF  THE  STOMACH 

rectum,  and  the  retroperitoneal  callosities,  should  these  latter  conditions 
be  present. 

The  following  case  will  exemplify  not  only  the  clinical  features  of 
the  disease,  but  also  the  difficulties  in  determining  the  true  nature 
of  the  lesion  and  its  differentiation  from  ulcer  or  cancer. 

■Miss  A.  B.  C,  aged  thirty-eight  years,  seen  April  2,  1908.  Except 
for  occasional  attacks  of  vomiting,  extending  over  the  period  of  one 
year,  when  she  was  a  little  girl,  there  had  been  no  history  of  illness  or 
of  any  gastric  distress  whatever,  until  six  months  ago,  when  she  began 
to  complain  of  the  eructations  of  gas  having  a  "rotten-egg"  odor,  and 
of  occasional  outbreaks  of  diarrhea.  She  began  to  lose  flesh  and 
strength,  but  has  not  had  pain,  nausea,  or  vomiting. 

Examination.- — Patient  fairly  well  nourished  and  does  not  seem  ill. 
A  rounded,  smooth,  insensitive,  and  freely  movable  mass  the  size 
of  a  horse-chestnut  is  distinctly  palpable  one  inch  to  right  and  one 
inch  above  the  umbilicus.  The  lower  border  of  the  stomach  by  inflation 
is  4  cm.  below  the  navel. 

Gastric  Analysis. — The  fasting  stomach  contains  120  c.c.  of  well- 
digested  food  remains  and  fruit  skins  and  seeds,  separating  on  standing 
into  two  layers  of  equal  depth.  Total  acidity,  50;  free  hydrochloric 
acid,  28;  lactic  acid,  a  trace;  no  occult  blood.  Microscopic  examina- 
tion revealed  rod-shaped  bacilli  and  some  non-sprouting  yeast,  but 
no  sarcinse. 

Test  Breakfast. — 220  c.c,  well  digested,  separating  on  standing  in 
two  layers  of  equal  depth.  Total  acidity,  64;  free  hydrochloric  acid, 
28;  lactic  acid,  a  doubtful  trace.  The  diagnosis  of  pyloric  cancer  was 
made,  and  on  April  22,  1908,  Dr.  W.  J.  Mayo  excised  three-fifths  of 
the  stomach. 

Recovery  from  operation  was  uneventful.  For  twenty  months  the 
patient  was  free  from  all  gastric  symptoms,  and  except  for  some  general 
lack  of  strength,  seemed  as  w^ell  as  ever.  In  February,  1910,  after 
family  illness  with  attendant  worry  and  fatigue,  the  appetite  became 
poor  and  she  began  to  suffer  from  attacks  of  vomiting  of  acid  fluid. 
These  attacks  came  every  three  to  five  days,  and  were  i)receded  for 
several  hours  by  epigastric  discomfort,  which  was  completely  relieved 
by  the  xoniiting  of  about  a  (juart  of  acid  fluid  and  some  food  remains. 
Microscopically,  the  vomited  matters  contained  a  considerable  amount 
of  granular  detritus,  with  numerous  pus  cells,  some  blood  cells,  and 
fatty  acid  crystals.  Organized  tissue  could  not  be  found.  Bile  pigment 
and  lactic  acid  were  present.  Staining  shows  ()p))l(T-Boas  bacilli  and 
non-pathogenic  organisms,  but  pyogenic  cocci  could  not  be  demon- 
strated  on  culture. 

The  fasting  stomach  contained  10  c.c.  of  greenish,  viscid  fluid  con- 


DIAONOSIS  87 

taining  microscopical  food  remains  and  many  Oppler-Boas  bacilli. 
Total  acidity,  10;  free  hydrochloric  acid  absent,  lactic  acid  absent. 
No  occult  blood. 

The  test  breakfast  showed  10  c.c,  yellow,  pasty  in  appearance; 
traces  only  of  gastric  mucus.  Total  acidity,  10;  free  hydrochloric 
acid  negative;  no  lactic  acid;  no  blood. 

The  course  from  this  time  onward  was  one  of  progressive  weakness. 
There  was  no  actual  pain,  but  continual  distress  increased  by  the 
taking  of  food.  Every  three  to  four  days  the  discomfort  would  be 
more  extreme,  and  would  then  be  temporarily  relieved  by  vomiting,  as 
above  described.  Death  occurred  six  months  after  the  second  accession 
of  symptoms,  a  little  over  two  and  one-half  years  after  the  first  onset 
of  the  disease. 

There  was  considerable  discussion  about  the  exact  nature  of  the 
lesion.  The  surgeon  regarded  it  as  malignant  at  the  time  of  operation. 
The  writer  regarded  the  subsequent  course  quite  characteristic  of 
malignancy.  Pathological  reports  varied.  The  pathological  report  at 
the  time  was  "carcinoma  (?)"  with  the  additional  note:  "There  is  an 
adenomatous  hypertrophy,  but  it  is  impossible  to  say  whether  or  not  it 
has  begun  to  be  carcinomatous."  Another  pathologist,  equally  emi- 
nent, reported:  "The  specimen  is  typical  of  cirrhosis  ventriculi;  the 
connective-tissue  coat  is  much  thickened;  the  mucous  membrane 
intensely  mammillated;  the  thickening  of  the  connective-tissue  coat 
at  the  pylorus  is  sufficient  to  give  marked  pyloric  thickening.  The 
glands  are  not  involved,  nor  is  there  any  evidence  of  peritoneal 
inflammation." 

Differential  Diagnosis. — Cancer. — The  differentiation  of  cirrhosis  of 
the  stomach  from  cancer  is  w^ell-nigh  an  impossibility.  It  is  well, 
therefore,  to  regard  the  case  as  malignant  until  positive  proof  of  its 
benign  origin  can  be  obtained. 

Benign  Stenosis. — In  the  localized  form,  in  which  the  fibrous  tissue  is 
concentrated  in  the  pylorus,  with  subsequent  narrowing  at  that  orifice, 
it  may  be  difficult,  or  impossible,  to  determine  whether  we  are  dealing 
with  such  a  condition,  or  with  a  callous  thickening  about  the  base  of 
indurated  ulcer  in  the  pyloric  portion  of  the  stomach.  Fortunately, 
however,  such  a  differentiation  is  of  very  little  importance,  as  the 
treatment  of  the  two  conditions  by  surgical  means  is  the  same. 

Syphilis. — There  are  forms  of  diffused  infiltration  which  histologi- 
cally resemble  very  closely  cirrhosis  of  the  stomach,  and  which 
clinically  run  an  almost  identical  course.  In  doubtful  cases,  therefore, 
a  Wassermann  test  should  be  made,  and  remedies  directed  toward 
this  specific  affection  should  be  given  a  fair  trial. 


88  CIRRHOSIS  OF  THE  STOMACH 

Cirrhosis  of  Liver  and  Tiiherculous  Peritonitis.  —  When  ascites  is 
present  linitis  plastica  may  resemble  cirrhosis  of  the  liver,  or  tuber- 
culous peritonitis.  A  careful  study  of  the  case  in  all  of  its  aspects 
should  ordinarily  clear  up  the  diagnosis  without  much  difficulty. 

Duration. — Duration  is  uncertain,  as  in  many  instances  the  disease 
becomes  well  established  before  it  gives  rise  to  symptoms.  As  a  rule, 
the  course  of  the  disease  extends  over  but  a  few  years,  two  years  being 
about  the  average  period  of  time  from  the  onset  of  symptoms  until 
the  fatal  issue.  Cases  have  been  reported  as  having  existed  for  ten 
years  or  more,  but  these  are  in  all  probability  instances  of  callous  ulcer 
of  the  pylorus,  with  dilatation  of  the  stomach.  In  general  terms  the 
duration  is  that  of  cancer. 

Prognosis. — Prognosis  is  most  grave.  Unrelieved  by  surgical  inter- 
vention the  outcome  is  invariably  fatal. 

Treatment. — Medical  Treatment. — Medical  treatment  is  entirely 
symptomatic,  and  is  directed  rather  toward  the  reduction  of  distressing 
symptoms  than  with  the  hope  of  any  possible  effect  upon  the  progression 
of  the  disease. 

In  the  early  stages  some  relief  may  be  afforded  by  lavage,  especially 
in  localized  fibrosis  of  the  pyloric  region.  Here  an  indication  for  the 
washing  of  the  stomach  is  to  be  found  by  the  presence  of  food  remains 
in  the  fasting  state.  There  are  patients  who  are  apparently  much 
benefited  by  lavage,  even  though  the  motor  function  is  well  preserved, 
and  the  lavage  water  returns  clear.  It  is  probable  that  the  improve- 
ment in  such  instances  is  entirely  psychic. 

Artificial  aids  to  digestion  maj'  be  advised  whenever  hydrochloric 
acid  is  diminished,  and  the  gastric  digestion  becomes  thereby  impaired. 
Dilute  hydrochloric  acid  may  be  given  with  or  after  meals.  As  the 
capacity  of  the  stomach  is  usually  diminished,  it  is  often  better  not  to 
give  the  acid  which  requires  bulk  of  dilution  with  water,  but  to  pre- 
scribe oxyntin,  with  or  without  pepsin  or  acidol.  The  following  may 
be  recommended: 

I^ — Capsule  oxyntin  with  pepsin  (Fairchild) gr.  x 

Sig. — Such  a  capsule  with  each  meal. 

The  treatment  of  the  vomiting  is  usually  ineffective  by  medicinal 
means,  as  the  vomiting  occurs  simply  as  the  natural  result  of  putting 
food  into  a  indistensible  contracted  stomach  of  limited  capacity. 
Small  doses  of  strontium  bromide  may  be  given  with  or  without 
codeine,  but  the  greatest  relief  will  follow  the  giving  of  a  suitable  diet. 

Should  the  patient  give  a  specific  history,  or  should  the  Wassermann 
reaction  be  positive,  a  thorough  antisyphilitic  treatment  should  be 
administered.    Syphilis  must  always  be  considered  a  possibility. 


TREATMENT  89 

The  principal  rule  for  diet  is  to  give  highly  nutritious  food  in  small 
quantities  at  frequent  intervals.  The  quantity  suitable  for  each  meal 
has  to  be  determined  by  individual  experience  in  each  case.  There  is 
a  point  past  which  nourishment  cannot  be  forced  without  resulting 
distress  and  vomiting,  and  the  main  indication  for  diet  is  to  keep 
within  these  limitations.  The  quality  of  food  makes  very  little 
diflference  as  long  as  a  nutritious  selection  is  made. 

Surgical  Treatment. — As  the  disease  cannot  be  differentiated  from 
cancer,  and  as  there  is  a  growing  inclination  to  regard  all  the  cases  as 
instances  of  malignant  disease,  the  surgical  treatment  is  that  of  actually 
proved  malignancy. 

Should  the  lesions  be  confined  to  the  pylorus,  partial  gastrectomy 
should  be  attempted.  The  more  thoroughly  the  diseased  tissue  is 
removed,  the  better. 

Should  the  walls  of  the  stomach  be  diffusely  infiltrated,  gastro- 
jejunostomy as  a  palHative  operation  is  to  be  advised.  The  results  of 
such  an  operation  are  often  surprisingly  good,  a  number  of  patients 
being  reported  in  good  health  two  or  three  and  one-half  years  afterward. 

If  the  disease  has  progressed  so  far  that  the  cavity  of  the  stomach  is 
practically  insufficient  to  hold  enough  nourishment  to  support  the 
strength  of  the  patient,  or  if  the  walls  are  too  thickened  and  dense  to 
allow  of  a  proper  juxtaposition  with  the  duodenal  loop,  duodenostomy 
or  jejunostomy  may  be  the  last  resort. 


CHAPTER   IV 
ACUTE  AND   CHRONIC   ULCER 

Gastric  and  Duodenal  Ulcer. — In  former  years  ulcerations  in  the 
upper  alimentary  tract  were  considered  as  being  almost  entirely  gastric 
— duodenal  ulcerations  being  treated  with  but  scanty  reference.  In 
late  years,  however,  duodenal  ulcer  has  assumed  a  more  prominent 
position  in  clinical  pathology,  and  ulceration  of  gastric  origin  has 
shrunk  somewhat  into  the  background.  It  is  largely  to  the  surgeons 
that  we  owe  our  present  state  of  knowledge  on  this  subject,  and  w^e 
gladly  acknowledge  our  great  indebtedness  to  them  for  this  and  for 
other  matters  of  gastric  pathology. 

It  has  become  quite  the  fashion,  however,  to  draw  a  too  well-defined 
line  betw^een  them,  as  shown  by  the  large  and  increasing  number  of 
monographs  entitled  "duodenal  ulcer"  which  appear  in  our  periodicals, 
as  if  duodenal  ulcer  were  an  entity  quite  distinct  from  ulceration 
occurring  on  the  proximal  side  of  the  pyloric  ring.  The  writer  concedes 
that  gastric  and  duodenal  ulcers  may  run  their  course  distinguishable 
clinically  from  each  other  in  the  majority  of  instances — nevertheless 
there  are  cases  of  ulceration  which  it  is  clinically  impossible  accurately 
to  locate  at  either  the  i)roximal  or  the  distal  side  of  the  pylorus.  We 
can  say  they  are  juxtapyloric,  but  farther  than  this  we  cannot  go. 
Moreover,  in  pathogenesis,  in  pathology,  in  prognosis,  and  in  treat- 
ment, it  practically  makes  little  difference  where  the  ulcer  lies.  Embryo- 
logical  ly  the  stomach  and  the  upper  four  inches  of  the  duodenum  are 
derived  from  the  foregut,  and  are  therefore  somewhat  associated  in 
function  and  pathology. 

Accordingly,  in  the  following  article  the  ordinary  forms  of  gastric 
and  duodenal  ulcers  will  be  considered  together.  An  attempt  will, 
however,  be  made  to  difi'erentiate  them  whenever  they  show  difi'erences 
in  their  pathological  or  in  their  clinical  course,  whenever  such  differen- 
tiation is  of  any  real  interest  in  the  study  of  the  subject. 

An  important  distinction  is  to  be  made  between  the  acute  or 
"mucous"  and  the  chronic  or  "indurated"  ulcer.  They  differ  from 
one  another  not  only  in  certain  details  of  their  pathogenesis,  but  also 
in  their  location,  number,  size,  and  clinical  history,  and  are  radically 
different  in  their  resj)ective  treatments.  According  to  some  authorities, 
the  acute  mucous  ulcer  does  not  apparently  give  rise  to  the  chronic 
indurated  form,  but  definite  proof  of  this  statement  is  lacking. 


FREQUENCY  OF  ACUTE  AND  CHRONIC   ULCER  91 

These  differences  will  be  noted  throughout  the  following  pages, 
whenever  differences  exist,  without,  however,  separating  the  two  forms 
from  each  other  under  entirely  separate  and  distinct  headings.  It  is 
believed  that  in  this  way  their  respective  features  will  be  more  clearly 
contrasted  and  emphasized.  Erosions  and  the  rarer  forms  of  gastric 
and  of  duodenal  ulceration,  as  well  as  the  jejunal  ulcers  which  follow 
gastro-jejunostomy,  will  be  considered  under  separate  headings. 

Frequency. — To  determine  the  frequency  of  ulcer  two  methods 
may  be  adopted,  both  of  which  are  open  to  serious  objections. 

The  first  method  is  to  note  the  percentage  of  cases  of  ulcer  which 
occurs  in  a  large  number  of  autopsies  performed  on  those  dying  from 
a  variety  of  different  diseases. 

The  most  frequently  quoted  figures  are  those  of  Welsh,  which  tend 
to  show  that  gastric  ulcer,  open  or  cicatrized,  occurs  in  5  per  cent,  of 
all  mankind.  Fenwick  found  that  either  an  open  ulcer  or  a  cicatrix 
was  present  in  4.2  per  cent,  of  47,912  autopsies.  Small  cicatrices  are, 
however,  easily  overlooked,  and,  moreover,  it  is  far  more  interesting 
to  determine  the  frequency  of  ulcers  that  are  unhealed  at  the  time  of 
death.  It  is  evident  that  those  who  adopt  the  method  of  computing 
only  those  cases  in  which  an  actual  ulcer  is  present  will  consider  ulcer 
much  less  frequent  than  those  who  include  in  addition  all  the  cases  in 
which  old  cicatrices  are  present,  and  it  is  ow4ng  to  this  difference  in 
statistical  methods  that  the  various  estimates  vary  so  greatly.  Whereas, 
according  to  the  first  method,  it  may  be  said  that  about  4  or  5  per 
cent,  of  the  entire  population  suffer  at  one  time  or  another  from  the 
disease,  it  is  probable  that  only  1  per  cent,  of  persons  dying  from  all 
causes  show  the  presence  of  ulcer  in  a  more  or  less  active  state. 

Furthermore,  ulcer  occurs  far  more  frequently  in  some  countries 
than  in  others,  being  more  common  in  Denmark  and  in  northern 
Germany  than  in  France  or  Russia. 

In  Copenhagen  ulcer  was  found  post  mortem  in  20 .  00  per  cent. 
In  Dresden  ulcer  was  found  post  mortem  in  11 .  00  per  cent. 
In  Tiihingen  ulcer  was  found  post  mortem  in  10.00  per  cent. 
In  Zurich  ulcer  was  found  post  mortem  in    2.20  per  cent. 

In  Munich  ulcer  was  found  post  mortem  in    1 .  23  per  cent. 

In  the  United  States  the  frequency  is  much  less  than  in  Europe,  as 
is  shown  in  the  following  table: 

Name  of  author. 

Francine  (Philadelphia) 

Kelly  (German  Hospital) 

Howard  (Hospitals  of  United  States) 
Mallary  (Boston  City  Hospital)      .... 

Brooks  (Bellevue  Hospital) 

Lockwood  (Bellevue  Hospital)       .... 


^^umber  of 

Number  of 

autopsies. 

ulcers. 

Per  cent. 

2937 

41 

1.39 

937 

13 

1.38 

10,841 

144 

1.32 

2,600 

25 

0.90 

1,000 

9 

0.90 

1,000 

6 

0.60 

92  ACUTE  AND  CHRONIC  ULCER 

It  is  to  be  remembered,  however,  that  these  figures  do  not  necessarily 
mean  that  in  these  cases  the  ulcer  was  the  cause  of  death,  but  simply 
that  at  the  time  of  death  an  ulcer  was  found.  Neglect  to  appreciate 
this  fact  gives  an  erroneous  idea  of  the  mortality  of  ulcer.  In  1000 
autopsies  at  Bellevue  Hospital,  compiled  by  the  writer,  there  were  6 
cases  in  which  ulcer  was  found.  The  cause  of  death  in  1  case  was 
perforation,  in  2  cases  lobar  pneumonia,  in  1  case  bronchopneumonia, 
and  in  2  cases  nephritis,  so  that  in  only  1  of  the  6  cases  could  ulcer  be 
considered  the  actual  cause  of  death.  It  does  not  seem,  after  all  is 
considered,  that  these  pathological  statistics  are  of  much  value  in 
determining  the  frequency  in  the  living  patient. 

The  second  method  of  computing  the  frequency  of  gastric  ulcer  is 
based  on  clinical  observation,  and  concerns  the  percentage  of  a  large 
number  of  patients  suffering  from  various  diseases,  who  are  diagnos- 
ticated as  suffering  from  ulcer.  Such  statistics  must  necessarily  be 
very  unreliable  because  of  the  impossibility  of  knowing  whether  or  not 
the  diagnosis  has  been  correct.  IMany  ulcers  run  an  obscure  or  latent 
course,  and  are  overlooked,  while  in  others  with  gastric  symptoms  the 
diagnosis  is  incorrectly  made. 

Here,  too,  the  personal  equation  of  the  observer  must  be  taken  into 
account.  One  clinician  will  be  conservative  and  will  include  only  the 
frank  outspoken  cases,  while  another  will  be  less  wary  in  making  a 
positive  diagnosis. 

In  general  terms,  however,  it  may  be  said  that  clinical  experience 
leads  us  to  believe  that  gastric  ulcer  is  far  less  common  than  we  might 
infer  from  pathological  evidence.  Lebert,  in  41,688  patients  in  his 
care  in  Zurich  and  Breslau,  diagnosticated  the  disease  in  only  252 
cases  (0.()  per  cent.).  Fenwick,  out  of  45,712  cases  at  the  London 
and  London  Temperance  Hospital  in  ten  years,  considered  only  383, 
or  about  0.8  per  cent.,  as  suffering  from  gastric  ulceration. 

Howard,  in  101,599  medical  admissions  in  various  hospitals  in 
the  United  States,  found  the  clinical  diagnosis  of  ulcer  in  930,  or 
0.57  per  cent. 

In  Bellevue  Hospital  from  1904  to  1908,  out  of  00,028  medical  cases,. 
there  were  admitted  only  55  cases  of  gastric  ulcer,  and  of  these  1 1  were 
excluded  by  the  writer  as  totally  inconclusive. 

The  frequency  of  ulcer  in  private  practice  is  often  estimated  by  the 
percentage  of  ulcer  cases  that  occur  in  those  alone  which  are  suffering 
from  indigestion  and  gastro-intestinal  disorders,  and  therefore  the 
apparent  fre(iuency  is  somewhat  greater.  In  the  writer's  i)rivate 
practice,  3  per  cent,  of  patients  complaining  of  gastro-intestinal  dis- 
orders have  sufl'ered  from  gastric  or  duodenal  ulceration.  This  is  very 
close  to  Sawyer's  report  of  03  ulcers  in  1800  gastric  cases  (3.5  per  cent.). 


POSITION  OF   ULCERS  93 

On  the  other  hand,  Friedenwald  makes  a  somewhat  higher  estimate, 
for  in  12,598  patients  complaining  of  digestive  disorders,  ulcer  was 
diagnosticated  in  7  per  cent. 

Relative  Frequency  of  Gastric  and  Duodenal  Ulcer. — Ulceration  of 
the  stomach  or  duodenum  may  exist  whenever  unneutralized  gastric 
juice  comes  in  contact  with  the  mucosa.  Formerly  gastric  and  duodenal 
ulcers  were  not  as  clearly  distinguished  from  each  other  as  they  now 
are,  partly  from  lack  of  care  in  locating  them,  and  partly  because,  in 
the  presence  of  ulceration  or  of  extensive  adhesions,  it  may  be  quite 
difficult  to  locate  the  pylorus  accurately.  W.  J.  Mayo  has,  however, 
called  our  attention  to  the  value  of  the  pyloric  vein  as  a  landmark. 
This  vein  extends  from  the  inferior  margin  of  the  pylorus  on  its  gastric 
side,  upward,  and  across  for  three-fourths  of  an  inch.  A  similar  vein 
from  above  extends  downward  until  it  nearly  or  quite  meets  the  one 
from  below.  Ulcers  formerly  regarded  as  pyloric  are  now  generally 
considered  to  be  of  duodenal  origin. 

The  relative  frequency  with  which  the  stomach  and  the  duodenum 
are  found  at  operation  to  be  invaded  by  the  ulcerative  process  is  now 
agreed  upon  by  all  surgeons.  Of  1000  cases  of  chronic  indurative 
gastric  and  duodenal  ulcer  operated  on  by  Wm.  J.  Mayo,  428  were 
gastric,  572  were  duodenal.  Mayo's  later  statistics  show  that  duodenal 
ulcers  are  really  more  frequent  than  this,  for  in  621  cases  operated  on 
between  June  1,  1906,  and  January  17,  1911,  32.5  per  cent,  were  gastric, 
and  64.5  per  cent,  were  duodenal,  while  in  3  per  cent,  one  or  more 
ulcers  of  both  stomach  and  duodenum  were  encountered. 

It  cannot,  however,  be  argued  that  these  figures  are  correct  for  all 
ulcers.  The  figures  just  given  hold  good  only  for  the  location  of  such 
chronic  unhealed  ulcers  that  come  to  operation.  Acute  ulcers  that  heal 
spontaneously  or  by  medical  aid — chronic  ulcers  in  parts  of  the  stomach 
that  may  be  considered  more  or  less  silent  areas,  and  which  do  not, 
therefore,  run  an  aggressive  course,  and  chronic  ulcers  both  gastric 
and  duodenal,  which  are  relieved  by  medical  means  to  such  an  extent 
that  they  do  not  come  under  the  surgeon's  care,  are  not  included  in 
such  a  table  of  statistics  as  that  of  Mayo's  just  quoted.  How  great  a 
number  of  these  non-operative  cases  there  are  cannot  be  computed, 
nor  can  it  be  said  that  the  location  of  such  ulcers  is  that  of  those  which 
are  demonstrable  at  operation.  In  point  of  fact,  surgical  statistics  for 
ulcer  are  true  only  as  far  as  they  apply  to  cases  seen  by  the  surgeon, 
but  they  do  not  allow  of  correct  conclusions  when  applied  to  the  various 
types  of  ulcer  both  acute  and  chronic,  aggressive  and  comparaiively  quiescent, 
which  come  under  the  care  of  the  internist. 

Position  of  Ulcers. — Location  of  Gastric  Ulcers. — Chronic  Ulcer. — 
Eighty-five   per    cent,    of   chronic   gastric   ulcers   involve   the   lesser 


94  ACUTE  A\D  CHRONIC   ULCER 

curvature  near  the  pylorus  and  extend  downward,  both  anteriorly  and 
posteriorly,  in  a  manner  compared  to  a  saddle.  The  posterior  ulcer 
is  usually  the  more  extensive.  The  canal  of  Jonnesco — the  name 
given  to  the  terminal  three-fourths  of  an  inch  of  the  pyloric  canal — 
is  not  frequently  involved,  because  this  canal  does  not  take  part  in 
the  grinding  function  of  the  antrum,  and  is  therefore  less  exposed  to 
mechanical  injury.  In  a  small  proportion  of  cases  the  ulcer  has  been 
found  at  other  parts  of  the  stomach,  with  some  apparent  predilection 
for  the  posterior  wall  and  the  neighborhood  of  the  cardiac  orifice. 

Acute  Ulcers. — The  acute  ulcers  are  more  generally  distributed  over 
the  surface  of  the  gastric  mucosa.  This  point  is  well  illustrated  by 
the  following  table  of  Fenwick's: 

Chronic  ulcers.     Acute  ulcers. 

Pyloric  region 53  13 

Middle  zone 7  14 

Near  the  cardia         10  12 

70  39 

Position  of  Duodenal  Ulcers. — According  to  Mayo,  96  per  cent,  of 
duodenal  ulcers  are  found  in  the  upper  portion  of  the  duodenum, 
extending  up  to  or  within  three-fourths  of  an  inch  from  the  pyloric 
sphincter.  This  is  in  accord  with  the  figures  given  by  Collins  and  by 
Perry  and  Shaw.  According  to  Collins,  duodenal  ulcers  were  located 
as  follows: 

In  first  portion 92.4  per  cent. 

In  second  portion 5.4  per  cent. 

In  third  portion 1.1  percent. 

In  fourth  portion 1.1  per  cent. 

Size  of  Ulcers. — Ulcers  vary  in  size  from  minute  erosions  hardly 
visible  to  the  naked  eye  up  to  1  cm.  to  3  or  4  cm.  in  diameter.  Ordi- 
narily the  acute  ulcers  are  of  the  size  of  a  split  pea  to  that  of  a  penny. 
Occasionally  they  are  much  larger  than  this,  especially  when  several 
have  coalesced,  so  that  large  areas  of  the  wall  of  the  stomach  are. 
involved  in  the  process. 

Chronic  ulcers  are  somewhat  larger  than  tlic  acute,  usually  ranging 
from  the  size  of  a  ten-cent  piece  to  that  of  a  half-dollar.  Occasionally 
chronic  ulcers  of  the  stomach  attain  very  large  dimensions,  so  that 
cases  are  recorded  in  which  the  ulcer  has  measured  more  than  (i  inches 
long  by- 3  inches  wide.  Peabody  has  reported  one  measuring  19  cm. 
by  10  cm.  In  exceptional  conditions  the  whole  surface  of  the  stomach 
between  the  pylorus  and  the  cardia  may  be  occupied  by  a  single  ulcer. 
These  large  ulcerations  are  more  often  due  to  the  coalescence  of  a 


DUODENAL   ULCERS  95 

number  of  separate  areas  than  to  the  invasive  tendency  of  a  single 
sore. 

Duodenal  ulcers  are  usually  quite  unimportant  in  size,  strikingly  so 
when  compared  with  the  pain  and  discomfort  which  they  cause.  They 
vary  in  size  from  that  of  a  split  pea  to  that  of  a  dime.  More  rarely 
they  are  of  the  size  of  a  quarter-dollar,  while  in  very  exceptional 
instances  several  inches  of  the  bowel  may  be  involved. 

Number. — Ulcer  of  the  stomach  is  often  spoken  of  as  if  it  were 
solitary,  whereas  in  many  instances  multiple  ulcerations  are  found. 
This  should  especially  be  borne  in  mind  when  exploring  the  stomach 
surgically,  for  the  finding  of  an  ulcer  by  such  a  procedure  does  not 
relieve  the  surgeon  from  the  responsibility  of  making  a  further  search. 

Acute  ulcers  are  more  apt  to  be  multiple  than  is  the  chronic  form. 
The  older  statisticians  did  not  recognize  this  fact  as  clearly  as  we  do 
now,  and  in  estimating  the  proportion  of  cases  in  which  ulcer  was 
solitary,  included  in  their  series  both  acute  and  chronic  ulcers  without 
making  any  discrimination  between  them. 

Neither  was  there  any  attempt  apparently  made  to  separate  the 
gastric  from  the  duodenal  ulcerations.  For  these  reasons  the  older 
figures  are  quite  misleading.  Gastric  and  duodenal  ulcers,  and  the 
acute  and  chronic  form  of  each  should  be  separately  considered. 

Gastric  Ulcer. — In  867  cases  of  gastric  ulcer  of  both  acute  and  chronic 
forms  collected  by  Fenwick: 

1  ulcer  was  present  in 80.50  per  cent. 

2  ulcers  were  present  in 12. 10  per  cent. 

3  ulcers  were  present  in 3 .  10  per  cent. 

4  or  more  ulcers  were  present  in 4.  26  per  cent. 

When  this  writer  separated,  however,  the  acute  from  the  chronic 
form,  he  found  that  whereas  87  per  cent,  of  the  chronic  indurative 
gastric  ulcers  were  solitary,  a  single  sore  was  found  in  but  54  per  cent, 
of  the  acute  variety.  This  tendency  of  acute  non-indurated  ulcers 
to  be  multiple  has  been  verified  by  later  surgical  statistics. 

In  rare  instances  the  number  of  acute  ulcerations  present  in  the 
stomach  is  excessive.  Cases  have  been  reported  of  such  multiplicity 
that  it  has  been  almost  impossible  to  count  them. 

Recent  ulcers  are  occasionally  seen  on  parts  of  the  gastric  wall  that 
are  in  contact  with  older  ulcerations  on  the  opposite  wall  when  the 
stomach  is  collapsed.  To  them  the  name  of  contact  or  kissing  ulcer 
is  given. 

Duodenal  Ulcers. — Ulcers  of  the  duodenum  are  usually  solitary, 
except  the  acute  form,  which  shows  a  tendency  toward  multi- 
plicity. 


96  ACUTE  AND  CHRONIC   ULCER 

In  Fenwick's  cases,  including:  both  acute  and  chronic  forms: 

1  ulcer  was  present  in 86  per  cent. 

2  ulcers  were  present  in 9  per  cent. 

3  or  more  ulcers  were  present  in 5  per  cent. 

If  there  are  many  uk'ers  they  are  usually  crowded  together  in  the 
first  portion  of  the  duodenum,  and  the  contact  or  kissing  form  is  not 
infrequently  observed . 

Multiple  Gastric  and  Duodenal  Ulcers. — Ulcers  may  be  found  both 
in  the  stomach  and  in  the  duodenum  of  the  same  patient.  In 
INIoynihan's  earlier  cases  of  operation  for  fluodenal  ulcer,  a  concomitant 
gastric  ulcer  was  found  in  one-half  of  the  cases.  This  writer  quotes 
AY.  J.  INIayo  as  finding  the  same  proportion  in  the  cases  observed  by 
him.  Later  statistics,  however,  lead  us  to  believe  that  the  actual 
number  of  operative  cases  which  show  associated  gastric  and  duodenal 
ulcer  is  much  less  frequent  than  has  been  supposed.  In  021  cases  of 
gastric  and  duodenal  ulcer  operated  on  by  W.  J.  INIayo,  from  June  1, 
1906,  until  January  17,  1911,  only  3  per  cent,  showed  the  presence  of 
one  or  more  ulcers  of  the  stomach  and  duodenum.  It  has  been  sur- 
mised that  in  these  cases  the  gastric  ulcer  is  the  primary  sore,  the 
pathological  sequence  being  gastric  ulcer,  hyperchlorhydria,  and 
finally,  peptic  ulcer  in  that  portion  of  the  duodenum  which  first  suffers 
the  im])act  of  the  hyperacid  chyme. 

Sex  in  Ulcer. — It  was  formerly  supposed  that  ulcer  was  much  more 
common  in  women  than  in  men.  The  oldest  statistics  of  Welsh  show 
that  00  per  cent,  occurred  in  the  female  sex. 

In  Fenwick's  series  of  cases  the  proportion  in  females  was  as  three 
to  two.    These  figures  need  revision  at  the  present  time. 

According  to  ]\Iay(),  duodenal  ulcer  is  found  77  times  in  men  to  23 
times  in  women,  while  in  the  gastric  ulcer  the  percentage  runs  nearly 
even — 52  men  to  48  women.  This  increased  percentage  of  men  over 
women  in  duodenal  ulcer  is  a{)i)arently  due  to  the  diti'erence  in  the 
position  of  the  duodenum  in  the  two  sexes.  The  curve  of  the  first 
portion  of  the  duodenum  in  men  is  higher  and  more  ascending  than 
that  in  women,  so  that  the  alkaline  secretions  of  the  duodenum  less 
readily  neutralize  the  acid  chyme.  These  figures,  however,  apply  only 
to  those  cases  of  ulceration  which  come  to  ()])crntion,  and  do  not  include 
ulcers  that  are  not  surgically  treated. 

Bradshaw*  has  drawn  attention  to  this  point.  Of  77  cases  of  acute 
gastric  ulcer,  72.5  per  cent,  were  women.  Of  his  perforations,  50  in 
number,  71.5  per  cent,  were  females.    Of  his  cases  that  came  to  opera- 

1  Lancet,  August  20,  1910. 


AGE  IN   ULCER  97 

tion,  the  proportion  between  the  two  sexes  was  nearly  equal,  89  women 
and  84  men.  In  the  writer's  private  practice,  40  per  cent,  of  acute 
ulcers  and  68  per  cent,  of  chronic  ulcers  occurred  in  men. 

It  may  therefore  he  stated  that  acute  ulcer  of  the  stomach  is  three 
times  as  common  in  women  as  in  men,  that  in  chronic  ulcers  of  the 
stomach  the  proportion  between  the  two  sexes  is  equal,  while  in  chronic 
ulcer  of  the  duodenum,  three-fourths  of  the  cases  occur  in  men,  owing 
to  the  anatomical  peculiarities  of  the  first  portion  of  the  duodenum  in 
the  masculine  sex. 

Age  in  Ulcer. — In  most  autopsies  it  is  not  definitely  stated  whether 
the  ulcer  is  open,  healing,  or  healed,  nor  is  it  always  possible  from  the 
clinical  history  of  the  patient  to  decide  at  what  age  it  first  made  its 
appearance.    In  607  cases  of  open  ulcer  found  by  Welsh  there  were: 

Under  20  years 5.4  per  cent. 

Between  20  and  40  years 37.2  per  cent. 

Between  40  and  60  years ■.      .  36.5  per  cent. 

Over  60  years 20 . 7  per  cent. 

It  has  been  supposed  that  children  are  but  rarely  affected.  This 
may  be  true  as  to  gastric  ulcers,  but  duodenal  ulceration  in  infants  is 
not  uncommonly  encountered.  Chvostek,  in  87  autopsies  on  children 
under  the  age  of  ten  years,  found  duodenal  ulceration  in  5.  Of  these 
infants  1  was  three  hours  old,  1  was  four  days  old,  and  1  seven  weeks 
old. 

Collins  appears  to  consider  the  disease  comparatively  common  in 
childhood,  as  he  finds  in  279  reported  cases,  42  under  ten  years  of  age, 
and  of  these  17  occurred  in  the  first  year  of  life.  Duodenal  ulcer  is 
undoubtedly  a  cause  for  meleena  neonatorum,  and  IMoynihan  has 
reported  16  cases  of  melena  in  the  first  week  of  life,  in  which  duodenal 
ulcer  was  found  at  autopsy. 

The  cause  for  these  infantile  cases  is  probably  the  devitalization  of 
a  certain  area  of  the  gastric  or  duodenal  wall  by  emboli  that  originate 
from  thrombo.sis  of  the  umbilical  vein. 

It  may  be  said  that  acute  ulcerations,  both  gastric  and  duodenal, 
are  more  common  in  the  second  and  third  decade,  while  in  the  chronic 
form  the  symptoms  are  more  apt  to  appear  somewhat  later,  in  the 
third  and  fourth  decade. 

In  100  cases  of  the  writer's,  including  both  gastric  and  duodenal 
ulcers,  there  were: 

Between  10  and  20  years 2  cases 

Between  20  and  30  years 18  cases 

Between  30  and  40  years 36  cases 

Between  40  and  50  years 30  cases 

Between  50  and  60  years 8  cases 

Between  60  and  70  years 6  cases 

7 


98  ACUTE  AND  CHRONIC   ULCER 

Etiology. — As  early  as  1855  Virchow  announced  that  whenever 
the  nutrition  of  a  small  area  of  the  gastric  mucosa  was  seriously 
impaired,  chiefly  through  interference  with  its  blood  supply,  the  peptic 
powers  of  the  gastric  juice  produced,  by  self-digestion,  an  erosion  of 
this  area,  resulting  in  the  formation  of  a  gastric  ulcer.  Since  this 
time  our  knowledge  of  the  pathogenesis  of  ulcer  has  not  materially 
increased.  We  still  believe  that  in  the  formation  of  gastric  ulcer,  two 
essentials  are  necessary,  an  area  of  diminished  local  resistance  due  to 
some  nutritive  or  vascular  change,  and  the  digestion  of  this  devitalized 
area  by  gastric  juice.  It  has  been  found,  however,  that  some  ulcers 
experimentally  produced  heal  rapidly,  while  others  remain  open  and 
become  chronic. 

It  will  facilitate  the  discussion  of  the  subject  if  we  consider: 

1.  The  causes  for  the  local  diminished  resistance  in  the  gastric 
mucosa. 

2.  Conditions  influencing  self-digestion  of  this  area. 

3.  Conditions  which  hinder  the  rapid  healing  of  the  ulcer. 

Causes  for  the  Local  Diminished  Resistance  in  the  Gastric  Mucosa. — 
The  chief  causes  for  the  lowering  of  the  vitality  of  a  local  area  of  the 
gastric  mucosa  are  chiefly  of  a  vascular  character,  embolism,  throm- 
bosis of  the  terminals  of  the  gastric  arteries,  spasm  of  the  arterial  wall 
producing  local  anemia,  and  rupture  of  the  vessel  wall,  allowing  small 
submucous  hemorrhages  and  hematomas. 

Occlusion  of  a  Nutrient  Vessel. — That  ulcers  may  follow  embolism 
of  the  smaller  branches  of  the  gastric  arteries  has  been  experimentally 
proved  by  Panum,  who  produced  gastric  ulcer  by  injecting  wax  emul- 
sion in  the  femoral  artery  of  dogs,  while  Cohnheim  has  been  successful 
in  inducing  the  same  lesions  by  the  introduction  of  finely  powdered 
chromate  of  lead  into  the  coronary  artery.  The  oval  oblique  shape  of 
many  gastric  ulcers  seem  to  corroborate  this  theory. 

Clinically,  this  embolic  ulcer  is  seen  with  special  frequency  in  the 
gastric  ulcerations  of  newly  born  infants,  the  source  for  the  embolism 
l)eing  the  clot  in  the  umbilical  vein. 

Aside  from  these  cases  in  infants,  and  cases  in  which  emboli  arise 
from  disease  of  one  of  the  large  vessels  in  the  neighborhood  of  the 
stomach,  as  in  aneurysm  of  the  celiac  axis,  embolism  of  the  stomach  is 
exceedingly  rare,  and  can  hardly  be  regarded  as  one  of  the  usual  causes 
for  ulcer.  Of  110  fatal  cases  of  malignant  endocarditis  examined  at 
the  London  Hospital,  embolism  in  various  viscera  occurred  in  ()2  ])er 
cent.    In  not  a  single  instance  was  the  stomach  affected. 

F'enwick  founrl  that  whenever  artificial  emboli  were  thrown  into  the 
general  circulation  of  animals,  only  3  to  5  per  cent,  found  their  way 
into  the  gastric  arteries,  and  of  these  two-thirds  occupied  the  middle 


ETIOLOGY  99 

and  cardiac  zones.  In  no  instance  was  the  pyloric  region  or  duodenum 
alone  affected. 

Thrombosis  and  endarteritis  may  be  causative  factors.  These  are  not 
infrequently  the  cause  for  ulcers  complicating  carcinoma.  Rochemont 
records  the  case  of  a  perforating  ulcer,  owing  to  thrombosis,  extending 
from  the  base  of  a  neighboring  cancer  mass.  Superficial  ulcers  are 
not  uncommon  in  advanced  phthisis  of  thrombotic  origin  due  to 
lardaceous  diseases  of  the  arteries. 

Gradual  obliteration  of  a  nutrient  artery  in  chronic  ulcer  is  one  of 
the  causes  preventing  cicatrization. 

In  Howard's  cases  48.8  per  cent,  had  arterial  sclerosis,  and  in  22  per 
cent,  the  condition  was  well  advanced.  Arterial  sclerosis  is,  however, 
extremely  common  in  the  hospital  cases  from  w^hich  Howard  drew  his 
statistics,  whereas  ulcer  is  rare.  The  causal  reaction  of  arterial  sclerosis 
to  gastric  ulcer  has  not  been  definitely  proved,  inasmuch  as  the  gastric 
arteries  are  not  terminal,  but  end  in  a  large  capillary  network  allowing 
of  free  anastomosis. 

It  is  thought  that  in  prolonged  pyloric  spasm  the  pressure  on  the 
local  artery  wall,  passing  as  it  does  obliquely  through  the  muscular 
tissue  before  it  reaches  the  mucous  membrane,  might  be  sufficient  to 
temporarily  shut  off  the  blood  supply  and  allow  of  the  devitalization 
of  an  area  of  the  mucosa  in  that  neighborhood.  That  such  a  theory  is 
not  impossible  is  borne  out  by  the  experiments  of  Talma,  who  pro- 
duced ulcers  at  the  pylorus  of  animals  by  faradization  of  the  left  vagus 
at  a  time  when  the  stomach  was  distended  by  food,  thus  increasing  the 
tension  on  the  stomach  wall.  Direct  pressure  on  the  stomach  may  be 
followed  by  local  necrosis  and  ulceration.  In  the  London  Hospital 
records  are  described  two  cases  of  ulcer  due  to  the  adhesion  of  the 
sac  of  an  abdominal  aneurysm  to  the  posterior  aspect  of  the  stomach 
producing  a  local  point  of  pressure.  Cases  have  been  recorded  of 
ulcer  from  necrosis  consequent  upon  the  pressure  of  a  distended  gall- 
bladder. Inasmuch  as  the  gastric  veins  have  no  valves,  and  as  they 
form  an  elaborate  anastomosis  over  the  entire  organ,  localized  venous 
congestion  is  practically  impossible.  It  is  improbable  that  gastric 
ulcer  can  therefore  arise  from  any  interference  with  the  return  flow  of 
blood  in  the  veins. 

Hemorrhagic  Erosions  and  Submucous  Hemorrhages. — Hemorrhagic 
erosions  and  submucous  hemorrhages  are  common  in  those  diseases 
of  heart  and  lungs  which  lead  to  venous  congestion  of  the  abdominal 
viscera,  in  various  cachectic  conditions  seen  in  all  ages,  in  acute  infec- 
tions, and  in  postoperative  states,  especially  after  appendix  operations. 
It  is  from  such  hemorrhagic  erosions  that  postoperative  hematemesis 
is  due.    Similar  erosions  may  follow  artificial  toxemias,  such  as  follow 


100  ACUTE  AND  CHRONIC   ULCER 

large  doses  of  diphtheria  toxin  (Rosenaii).  These  erosions  may  occur 
either  at  the  fundus  or  at  the  pylorus,  may  be  superficial,  or  may 
extend  through  the  entire  thickness  of  the  submucosa,  show  a  grayish- 
red  floor  and  well-defined  edges  surrounded  by  a  zone  of  hemorrhagic 
infiltration.  They  are  small  in  size,  and  usually  multiple.  Healing 
usually  occurs  with  great  rapidity,  but  they  may  be  regarded  as 
occasional  antecedents  of  ulcer. 

Local  Injuries. — Local  injuries,  such  as  blows  in  the  epigastrium, 
pressure  of  mechanics'  tools,  such  as  shoemakers'  lasts,  drilling  machines, 
the  carrying  of  heavy  bodies  supported  in  part  by  resting  them  against 
the  stomach,  and  to  a  lesser  extent  the  continual  stooping  at  work, 
so  that  the  corsets  impinge  upon  the  epigastrium,  as  in  the  case  of 
seamstresses,  have  all  been  undoubted  factors  in  producing  gastric 
ulcers.  These  traumatic  cases  are  not  infrequent,  and  Ackermann, 
writing  from  Paul  Cohnheim's  clinic,  has  described  a  number  of  such 
cases.  Ritter,  Vanni,  and  Gross  have  all  produced  ulcers  by  blows 
on  the  stomach — the  blow  causing  submucous  hemorrhage  or  hema- 
toma, which  subsequently  becomes  eroded  so  that  an  ulcer  is  eventually 
produced. 

Toxemic  Theory. — The  toxemic  theory  of  the  formation  of  ulcers 
has  received  much  attention  of  late,  owing  chiefly  to  the  work  done 
by  Gandy,  and  later  by  Hort. 

Gandy  has  shown  that  in  practically  all  toxemias  there  are  formed 
minute  gastro-intestinal  ulcerations,  and  that  practically  in  all  gastro- 
intestinal ulcerations  there  is  toxemia.  Certain  ulcers  arising  in 
toxemia,  as  in  the  case  of  duodenal  ulcer  following  extensive  burns, 
are  closely  allied  to  simple  ulcer  in  their  acute  formation,  and  in  their 
tendency  to  hemorrhage  and  perforation.  Their  earliest  stage  is 
ecchymosis,  followed  by  sloughing,  hemorrhagic  erosion,  true  ulcera- 
tion, with  hemorrhagic  borders,  until  finally  we  have  either  a  perfor- 
ating ulcer,  a  chronic  ulcer  with  thickened  walls,  or  cicatrization. 
Gandy  has  found  all  of  these  forms  in  burns,  in  infantile  diseases,  and 
in  various  infections  including  erysipelas,  septicemia,  pyemia,  puerperal 
disease,  infections  of  the  genito-urinary  organs  in  both  sexes,  pneu- 
monia, typhoid,  and  a  variety  of  similar  diseases.  In  a  number  of  these 
infections  (lanfly  was  fortunate  enough  to  find  instances  of  each  step 
of  ulcer  formation.  Roberts  has  collected  IG  cases  of  ulcer  following 
operations  upon  the  urinary  bladder,  which  seems  to  corroborate  this 
theory. 

Tiirck  produced  ulcers  on  dogs  In-  feeding  them  with  cultures  of 
Bacilli  coli  communis  for  a  variable  period  of  time.  No  healing  was 
observed  while  the  feeding  with  bacilli  continued,  but  if  the  l)acillus 
diet  was  stopped,  cicatrization  rapidly  took  i)lace.    All  his  cases  showed 


ETIOLOGY  101 

signs  of  severe  toxemia,  such  as  hemolysis  and  parenchymatous  changes 
in  the  viscera.  These  changes  were  similar  to  those  produced  by 
Rosenau  in  animals  used  for  the  purpose  of  standardizing  diphtheria 
antitoxin. 

Hort,  who  is  an  exponent  of  the  toxemic  theory,  believes  that  in 
certain  toxemias  there  are  formed  a  hemorrhagin  which  allows  leak- 
age of  blood  from  the  arterial  wall,  and  a  mucolysin  which  destroys  the 
mucosa. 

The  hemorrhagins  produce  local  areas  of  ecchymosis,  and  when  the 
mucolysins  are  formed,  an  ulcer  is  developed  unless  antibodies  are 
elaborated. 

Weinland's  view  is  that  the  stomach  secretes  an  antipepsin  or  an 
antibody  which  prevents  self-digestion,  and  that  whenever  this  anti- 
pepsin  ceases  to  be  secreted  from  a  certain  area  of  stomach  wall,  there 
is  nothing  to  prevent  this  area  froili  being  eroded  by  its  own  gastric 
juice. 

Unfortunately,  detailed  proofs  of  Hort's  and  Weinland's  theories 
are  lacking. 

A  very  interesting  series  of  experiments  on  autodigestion  have  been 
made  by  Katzenstein.^  This  experimenter  introduced  a  loop  of  jejunum 
with  its  blood  supply  intact  into  an  animal's  stomach,  and  retained 
it  in  position.  On  the  third  day  the  animal  sickened,  and  died  on  the 
eighth  day.  Autopsy  showed  the  jejunal  loop  w^as  completely  digested. 
A  similar  result  was  obtained  by  the  introduction  of  the  spleen  into 
the  stomach  through  an  opening  in  its  wall.  A  loop  of  duodenum 
introduced  in  a  similar  way,  with  its  nutritional  vessels  preserved, 
was  found  on  the  fourteenth  day  totally  unaltered.  A  portion  of  the 
stomach  wall  itself  was  inverted  in  such  a  manner  as  to  be  practically 
a  foreign  body  lying  within  the  stomach.  Eleven  days  afterward  it 
was  found  totally  intact.  His  conclusions  are  that  living  tissue  nor- 
mally nourished  is  digested  by  the  gastric  juice  in  the  stomach  of  the 
same  animal,  with  the  exception  that  tissues  producing  gastric  juice, 
or  normally  bathed  in  gastric  juice,  when  submitted  in  the  same 
conditions,  are  not  in  any  way  affected. 

Whether  or  not  Katzenstein's  experiments  are  accurate  may  be 
doubted,  for  Reering  was  able  in  dogs  to  introduce  a  loop  of  transverse 
colon  into  the  stomach  of  the  same  animal  and  find  it  intact,  and 
without  trace  of  ulcers  after  thirteen  months,  provided  that  its  nutrition 
through  the  mesenteric  vessel  was  well  preserved. 

Causes  Influencing  the  Digestion  (Erosion)  of  the  Devitalized  Area. — 
For  self-digestion  to  occur,  a  certain  amount  of  peptic  power  of  the 

1  Berlin,  klin.  Woch.,  1908,  ii,  1749. 


102  ACUTE  AND  CHRONIC  ULCER 

gastric  juice  is  generally  considered  necessary;  in  fact  it  has  been 
believed  that  the  formation  of  a  gastric  ulcer  was  usually  preceded  by 
hyperacidity  and  consequent  increase  in  the  peptic  power  of  the 
gastric  contents. 

A  number  of  cases  have,  however,  been  observed,  in  which  recent 
ulcers  have  been  found  associated  with  carcinoma,  and  entire  absence 
of  any  acidity  whatever.  These  instances  are,  however,  rare  and 
accurate  observations  on  the  peptic  power  of  the  gastric  contents  in 
these  reported  cases  are  entirely  lacking.  It  may,  however,  be  affirmed 
that  undoubted  cases  of  acute  gastric  ulceration  occur  even  in  the 
absence  of  apparent  peptic  power  of  gastric  contents.  More  usually, 
however,  gastric  ulcer  occurs  with  normal  or  excessive  amounts  of 
hydrochloric  acid,  and  it  has  been  a  disputed  point  whether  the  hyper- 
acidity that  accompanies  ulcer  is  a  causal  factor  or  is,  on  the  other 
hand,  the  result  of  the  ulcer.  It  may  be  said  that  hyperacidity  with 
ulcer  is  less  frequent  than  ordinarily  supposed. 

Causes  Retarding  the  Healing  of  Ulcer. — It  is  a  well-known  fact  that 
ulcers  experimentally  produced  heal  rapidly  and  run  a  mild  clinical 
course.  It  is,  moreover,  the  universal  experience  that  frequently  in 
extracting  test  breakfasts,  small  pieces  of  the  mucous  membrane  of 
the  stomach  are  caught  in  the  eye  of  the  tube  and  forcibly  torn  loose, 
anrl  that  evil  results  from  such  a  traumatism  are  extremely  rare.  The 
writer  does  not  remember  ever  having  observed  any  disagreeable 
results  from  such  injuries,  although  it  must  be  said  that  the  majority 
of  such  evulsions  occur  with  achylia,  in  which  condition  ulcers  are 
extremely  rare.  It  is,  therefore,  plausible  that  a  very  large  number  of 
acute  ulcers  run  a  latent  course  and  heal  rapidly  and  completely. 
Other  ulcers,  however,  do  not  tend  to  heal,  but  persist  and  become 
more  or  less  chronic.  These  are  the  ulcers  that  eventually  give  symp- 
toms and  come  under  the  observation  of  the  physician. 

It  is,  therefore,  of  the  utmost  importance  to  discover  the  reasons  for 
the  persistence  of  ulcer,  as  it  is  along  such  lines  that  treatment  should 
be  directed. 

One  of  the  most  important  observations  on  this  point  was  made  by 
Quincke  and  Daettwyler,  who  proved  experimentally  that  artificially 
produced  ulcers  are  much  slower  in  healing  in  animals  previously 
rendered  anemic  by  venesection  than  in  healthy  and  plethoric  ones. 

Fiitterer  excised  small  pieces  of  mucous  membrane  in  animals  and 
then  kept  them  anemic  by  giving  them  blood-destroying  substances. 
By  doing  so  he  kept  the  ulcer  from  healing  and  reproduced  the  lesions 
of  chronic  gastric  ulcer,  especially  when  the  excised  area  was  in  the 
pyloric  end  of  the  stomach  near  the  lesser  curvature.  This  accords 
with  our  clinical  obscrvatif)!!  on  the  cure  of  gastric  ulceration  in  man 


PATHOLOGY  103 

— anemic  and  cachectic  states  regularly  antagonize  the  healing  of 
ulcer,  and  it  is  not  until  the  general  condition  of  the  patient  is  improved 
that  healing  of  the  ulcer  takes  place.  It  is  said  that  anemic  and 
chlorotic  girls  are  especially  liable  to  gastric  ulcer,  but  it  may  well 
be  that  they  are  no  more  liable  than  others  to  this  complaint,  but 
simply  that  in  them  the  ulcer  does  not  heal,  but  remains  open  and 
gives  rise  to  symptoms. 

Matthes  showed  that  after  cutting  out  a  piece  of  the  mucous  mem- 
brane of  the  stomach,  muscidar  contraction  closed  the  defect,  thus 
protecting  the  denuded  area  from  further  erosion  by  the  gastric  juice. 
In  commenting  upon  this  observation.  Block  suggested  that  the  absence 
of  heavy  folds  of  mucous  membrane  in  the  neighborhood  of  the  pyloric 
portion  of  the  stomach  and  the  absence  of  submucous  tissue,  pre- 
venting the  closure  of  the  defect,  accounted  for  the  prevalence  of  open 
ulcers  in  this  region.  The  formation  of  adhesions  between  the  base  of 
an  idcer  and  the  neighboring  parts,  while  helpfid  to  repair  by  placing 
the  ulcer  in  a  condition  of  comparative  rest,  may  also  prevent  the  base 
of  the  ulcer  from  undergoing  the  degree  of  contraction  which  is  necessary 
to  cicatrization. 

It  may  be  said  that  ulcers  heal  more  readily  in  conditions  of  low 
acidity  than  they  do  when  hyperacidity  exists.  This  fact  is  the  basis 
of  our  medical  and  surgical  treatment  of  idcer — to  lower  the  acidity 
by  medicine,  by  diet,  and  by  surgical  operations  on  the  stomach,  for 
it  is  generally  acknowledged  that  an  excessive  acidity  not  only  irritates 
an  open  sore  and  keeps  it  inflamed,  but  by  increasing  the  digestive 
activity  of  the  secretion,  it  helps  to  enlarge  the  size  of  the  idcer.  The 
writer  firmly  believes  that  the  persistency  of  pyloric  idcers  is  largely 
due  to  the  hyperacidity  which  accompanies  so  large  a  proportion  of 
these  cases,  while  ulcers  elsewhere,  that  are  not  attended  by  such  a 
liability  to  hyperacidity,  are  more  amenable  to  treatment  and  more 
easily  healed. 

Another  reason  for  this  non-healing  of  ulcers  in  the  pyloric  region 
is  undoubtedly  the  violent  muscular  action  of  the  tissues  on  which 
they  are  superimposed. 

To  sum  up:  The  preventable  causes  for  the  chronicity  of  gastric 
idcers  are: 

1.  Anemic  and  run-down  condition  of  patient. 

2.  Hyperacidity,  and  in  many  instances,  of  pyloric  implantation, 
hypersecretion  as  well. 

3.  Overmuscular  action  of  the  pyloric  portion  of  the  stomach. 
Pathology. — The  pathology  of  acute  ulcer  differs  materially  from 

that  of  the  chronic  form,  so  that  a  separate  description  is  required 
of  each. 


104  ACUTE  AND  CHRONIC  ULCER 

Acute  Gastric  or  Mucous  Ulcer. — Acute  gastric  or  mucous  ulcer  cannot 
usually  be  identifiecl  from  the  outside  of  the  stomach,  and  it  is  often 
with  great  difficulty  that  it  can  be  located,  even  after  the  stomach  has 
been  opened.  The  depth  of  the  ulceration  depends  upon  the  intensity 
of  the  erosive  process,  and  may  extend  only  one-half  way  through  the 
mucous  coat,  or  may  involve  the  outer  coats,  and  even  extend  through 
the  peritoneal  covering  to  form  a  perforation.  Its  base,  therefore,  is 
formed  of  whatever  structure  of  the  stomach  happens  to  be  at  the 
limitation  of  the  eroding  process. 


Fig.  19 


Acute  gastric  ulcer.  It  has  a  typical  funnel  shape  and  extends  deeply  into  the  nmscularis  M.  It 
is  partially  filled  with  debris,  D.  To  the  left  is  seen  the  overhanging  mucosa,  A,  and  submucosa,  B. 
To  the  right  these  coats  are  missing.  There  is  intense  round-cell  infiltration  (C,  C)  in  the  borders 
of  the  ulcer. 

The  ulcer  is  usually  round,  occasionally  oval,  and  often  appears  as 
though  it  were  punched  out  of  the  wall  of  the  stomach.  The  edges 
are  clean  and  smooth,  and  are  not  thickened.  The  floor  is  smooth, 
sometimes  necrotic.  If  the  ulcer  extends  through  several  of  the  coats 
of  the  stomach  it  may  present  a  funnel-shaped  appearance,  as  each 
successive  layer  of  the  stomach  is  usually  invohcd  to  a  less  extent  than 
the  preceding  one. 

Microscopically,  infiltration  with  leukocytes  or  lymphocytes,  or 
})oth,  may  be  seen  between  the  tubules  of  the  adjacent  otherwise 
healthy  mucous  membrane,  and  the  base  of  the  ulcer  is  similarly 


PATHOLOGY 


105 


infiltrated  and  necrotic.  In  the  acute  ulceration,  adhesions  to  the 
neighboring  part  are  not  ordinarily  found,  even  though  the  ulcer  extend 
to  the  serous  coat,  or  even  perforate.  Lymphangitis  is  often  present, 
radiating  from  the  base  of  the  ulcer. 

The  exulceratio  simplex,  described  by  Dieulafoy,  is  practically  an 
acute  mucous  ulcer,  broad  and  shallow,  extending  partially  or  com- 
pletely through  the  mucous  coat  of  the  stomach.  It  is  often  the  cause 
for  sudden  hematemesis,  but  the  bleeding  point  is  often  with  great 
difficulty  discovered,  even  after  the  stomach  has  been  opened.  Being 
only  a  type  of  acute  ulcer,  it  will  require  no  further  description. 


Fig.  20 


Pyloric  sphincter  seen  from  the  duodenal  side,  showing  duodenal  ulcer  infolded,  resembling 
fissure  in  ano.     (Codman.) 

Codman^  has  made  an  interesting  comparison  between  ulcer  of  the 
duodenum  and  fissure  of  the  anus.  Ulcer  of  the  duodenum  usually 
occurs  outside  the  pyloric  ring,  so  that  when  the  pylorus  is  contracted 
the  ulcer  lies  in  the  mucous  folds  just  as  a  fissure  of  the  anus  lies  in 
the  folds  of  the  anal  sphincter,  and  about  its  periphery  there  is  often 
a  certain  degree  of  inflammatory  induration.  This  infolding  of  the 
ulcer,  by  the  mucous  puckering  during  pyloric  closure,  explains  the 
freedom  from  pain  that  occurs  when  the  stomach  is  full  and  the  pyloric 
orifice  is  closed,  and  also  gives  us  an  explanation  of  the  pylorospasm, 
and  of  the  acute  exacerbations  which  are  characteristic  of  its  clinical 
course.  The  relation  of  the  ulcer  to  the  pyloric  sphincter  may  explain 
the  difficultv  of  healing,  which  is  so  characteristic  of  duodenal  ulcera- 


1  Boston  Medical  and  Surgical  Journal,  September  2,  1909. 


106 


ACUTE  AND  CHRONIC   ULCER 


tions,  because  they  are  constantly  opened  and  folded  in  again  by  the 
action  of  the  pyloric  sphincter. 

During  the  acute  exacerbations  the  thickening  caused  by  inflam- 
matory induration  may  keep  the  raw  surface  from  })eing  infolded. 

In  other  cases  a  round  pyloric  ulcer  may  spread,  first  encircling  the 
lumen  of  the  gut  so  as  to  form  an  annular  ulceration,  which  later 
progresses  toward  the  stomach. 

Chronic  Ulcers. — In  chronic  ulceration  we  find  an  attempt  at  repair, 
as  is  shown  by  the  deposit  of  dense  connective  tissue  in  the  base  and 
walls  of  the  sore.    It  would  seem  that  the  initial  erosion  of  the  mucosa 


Fig.  21 


'l^a  c<?a.iu¥e^V/^^'£zn  e 


Cross-section  of  a  small  gastric  ulcer  showing  thickening  of  stomach  wall  at  the  base.  (From 
Bloodgood's  collection  of  specimens  from  the  Surgical  Pathological  Laboratory  of  the  Jolms 
Hopkins  University.) 


by  the  necrotic  ])rocess  was  sufficiently  slow  for  the  formation  of  a 
barrier  of  scar  tissue  to  prevent  further  extension.  This  connective- 
tissue  l)arrier  may  further  undergo  necrosis,  thus  gradually  increasing 
the  depth  of  the  ulcer.  The  base  may  be  smooth,  or  rough  and  necrotic, 
especially  after  an  acute  attack  in  which  inflammatory  symptoms 
were  present.  The  base  is  composed  of  dense  connective  tissue,  infil- 
trating whatever  coat  of  the  stomach  has  finally  resisted  the  assault 
of  the  necrotic  process.  Thus  in  shallow  ulcers  the  base  may  consist 
of  the  terminal  ends  of  the  glands  and  of  infiltrated  interglandular 
stroma.  The  muscnlaris  is  often  greatly  hypertrophied.  In  instances 
of  (lecjxT  ulceration  the  base  may  be  composed  of  the  inflamed 
submucosa,   muscular,   or  even  the  sul)serous  coat. 


PATHOLOGY 


107 


The  adjacent  mucosa  may  or  may  not  show  hypertrophy.     In  the 
larger  ulcerations  hypertrophy  is  apt  to  occur,  and  is  shown  by  the 


Fio.  22 


Section  through  an  ulcer  with  an  extensively  infiltrated  base.     (Wilson  and  McCarthy.) 

Fig.  23 


:]^SiY "' 


S'^SiKjMJSSri^f.JrS?'!.,^  ,^..  .^     ,     ,.    -.  ,       ,"■  ti-^fi 


Z.\!Si->-ir^'r^^is^' 


Section  through  the  border  of  the  ulcer  showing  the  overhanging  hypertrophic  border. 
(Wilson  and  McCarthy.) 


projection  of  the  mucosa  over  the  edge  of  the  ulcer.  At  no  portion, 
however,  of  the  border  can  there  be  seen  any  trace  of  epithelial  cells 
dipping  below  the  mucosa  into  the  submucous  coat.    Lymphangitis  is 


108  ACUTE  AND  CHRONIC   ULCER 

frequently  found  radiating  from  the  points  of  the  affected  area. 
Lesions  of  chronic  gastritis  are  usually  found  in  the  neighborhood  of 
the  sore. 

The  inflammatory  hyperplasia  at  the  base  may  extend  to  and  involve 
the  serous  coat,  and  thus  may  lead  to  the  adhesion  of  the  ulcer  to  the 
neighboring  parts,  such  as  the  pancreas,  liver,  or  abdominal  wall. 
These  adhesions  are  conservative  in  their  nature,  and  tend  to  strengthen 
the  weakened  points  so  as  to  prevent  perforation.  In  course  of  time, 
however,  the  fibrous  tissue  at  the  point  of  adhesion  may  disappear, 
so  that  the  floor  of  the  ulcer  may  be  formed  by  the  neighboring  organ 
itself. 

In  many  cases  which,  to  all  appearances,  seem  to  be  simple  indurative 
ulcers,  indubitable  evidences  of  malignancy  are  present.  The  fixed 
and  in\-ariable  rule  should  therefore  be  that  every  exsected  ulcer 
should  be  carefully  examined  in  e^'ery  part  of  its  structure  for  epithelial 
elements. 

Chronic  ulcerations  are  almost  invariably  distinctly  visible  by 
inspection  of  the  stomach  or  duodeninii  at  the  time  of  an  exploratory 
operation.  They  can  be  readily  seen  and  felt.  To  this  rule  there  are 
few  if  any  exceptions. 

Mansell  Moullin^  has,  however,  made  the  statement  that  ulceration 
of  the  duodenum  (he  does  not  specifically  mention  the  stomach)  may 
occur  without  any  visible  change,  post  mortem  at  least,  being  visible 
on  the  serous  coat.  It  is,  however,  probable  that  if  such  cases  were 
examined  in  the  living  subject,  there  would  have  been  at  least  some 
local  redness  to  arouse  suspicion. 

Mayo  has  drawn  attention  to  the  fact  that  when  the  pylorus  is 
pulled  up  for  inspection,  the  traction  may  interfere  with  the  blood 
supply,  and  the  local  anemia  thus  produced  will  cause  a  white  spot  to 
appear  on  the  duodenum  just  below  the  pylorus.  This  may  be  easily 
mistaken  for  duodenal  ulcer. 

The  pathology  of  the  comj)lications,  such  as  adhesions,  perforations, 
and  hemorrhages,  will  be  considered  under  these  respective  headings. 

Healing  of  the  Ulcer. — 1.  The  more  acute  the  ulcer  the  more  readily^ 
does  it  heal  and  the  less  evidence  is  left  of  its  presence.  Small  acute 
ulcers  may  heal  so  that  the  scars  left  are  so  slight  as  to  be  unnoticeable. 
Deeper  ulcers  may  leave  a  smooth,  white  sj)<)t  where  the  stomach  wall 
is  a  little  thin  and  uncovered  by  normal  mucous  membrane.  Larger 
and  deeper  scars  may,  in  healing,  so  contract  as  to  form  puckers,  which 
if  sufficiently  extensive,  may  produce  various  and  manifest  deformities 
of  th«;  stomach.     Such  cicatricial  contraction  in  the  neighborhood  of 

•  Lancet,  March  2,  1912,  p.  oG3. 


ACUTE  GASTRIC   ULCER  '  109 

the  pylorus  readily  induces  a  pyloric  stenosis  with  dilatation  of  the 
stomach. 

2.  Duodenal  ulcers  may  heal  leaving  simply  a  deposit  of  cicatricial 
tissue  in  the  deep  layers,  and  the  mucous  membrane  is  replaced,  glands 
and  all.  The  only  way  to  detect  that  there  has  been  an  ulcer  is  a  gap 
in  which  the  muscular  layer  is  interrupted  instead  of  being  continuous. 

3.  The  ulcer  may  cicatrize  partially,  leaving  a  thickened,  dense, 
connective-tissue  mass,  which  contains  but  a  few  bloodvessels,  and 
which  shows  no  tendency  to  heal.  This  is  the  type  of  ulcer  which  is 
not  amenable  to  medical  treatment,  and  which  comes  most  frequently 
under  the  observation  of  the  surgeon. 

4.  The  ulcer  may  undergo  malignant  degeneration. 


ACUTE    GASTRIC   ULCER 

This  is  often  spoken  of  as  "acute  perforating  ulcer,"  owing  to  the 
frequency  of  this  special  complication,  and  as  "medical  ulcer,"  because 
it  is  conceded  even  by  the  surgeons  that  the  acute  forms  of  gastric 
ulceration  are  better  treated  by  medical  means  than  by  surgical.  The 
pathological  characteristics  of  the  acute  ulcer  have  been  elsewhere 
described.  Its  complications  and  sequelae  will  be  described  with  those 
of  the  chronic  form. 

Symptoms. — The  acute  ulcer  is  characterized  clinically  by  the 
frequency  in  which  it  runs  a  latent  course,  and  by  its  greater  tendency 
to  hemorrhage  and  perforation.  It  is  probable  that  in  a  very  large 
percentage  of  cases  the  ulcer  heals  quickly  without  symptoms,  or 
without  symptoms  sufficiently  definite  to  allow  of  any  diagnosis. 
The  patient  complains,  if  he  complain  at  all,  of  a  temporary  distress 
after  meals,  a  sense  of  fulness,  or  the  feeling  of  a  load  or  lump,  but  not 
intense  enough  to  necessitate  medical  advice.  It  is  only  if  severer 
symptoms  or  complications  should  ensue  that  the  correct  diagnosis 
is  made. 

.  Pain. — The  most  characteristic  symptom  is  pain.  According  to 
Fenwick  this  was  the  first  symptom  noted  in  21  per  cent,  of  his  cases, 
and  of  these  the  pain  was  severe  in  only  one-third,  while  in  two-thirds 
the  sensation  was  more  like  the  ordinary  distress  of  indigestion,  so 
that  in  his  series  of  cases  only  7  per  cent,  began  with  the  characteristic 
pain  ordinarily  ascribed  to  acute  gastric  ulcer.  In  the  writer's  cases, 
80  per  cent,  gave  pain  as  the  initial  symptom,  and  of  these  three- 
fourths  of  the  cases  described  the  pain  as  well-marked  and  fairly 
characteristic. 

The  pain  varies  from  a  burning  or  gnawing  sensation  to  a  feeling 


no  ACUTE  AND  CHRONIC   ULCER 

of  soreness  in  the  epigastrium  or  a  painful  sense  of  lump  or  oppression. 
It  is  usually  located  in  the  epigastrium,  more  rarely  in  one  or  the 
other  hypochrondriac  regions,  with  a  tendency  to  run  to  the  back.  In 
some  instances,  usually  with  ulcers  of  the  posterior  wall,  the  pain  is 
felt  more  severely  in  the  back,  or  may  be  felt  in  the  back  alone.  The 
pain  may  occur  within  fifteen  to  twenty  minutes  after  the  ingestion 
of  food,  or  it  may  be  deferred  until  one  or  two  hours  after  eating.  A 
gastric  ulcer  may  remain  painless  unless  complicated  by  lymphangitis, 
in  which  case  the  pain  is  occasioned  by  normal  peristalsis.  In  this  way 
pain  of  acute  ulcer  or  acute  exacerbation  of  chronic  ulcer  may  occur 
soon  after  eating  and  continue  until  the  stomach  becomes  empty. 

The  duration  varies.  It  may  last  but  a  short  time,  or  may  continue 
until  the  stomach  empties  itself.  In  some  cases,  usually  of  ulcers  at 
or  near  the  pylorus,  with  pyloric  spasm  and  hypersecretion,  it  may  be 
more  or  less  continuous. 

Relief  from  pain  occurs  in  almost  all  cases  after  emesis — a  fact  so 
well  known  to  the  patients  themselves  that  they  induce  vomiting  for 
the  relief  it  affords.  In  many  cases  the  relief  is  complete  until  the  next 
meal,  while  in  other  cases  the  relief  is  but  partial.  Alkaline  drinks  and 
soda  tablets  may  give  relief,  especially  if  there  be  hypersecretion. 
Powders  of  anesthesine  and  orthoform  (aa  gr.  x)  will  often  afford  com- 
plete relief.  This  fact  is  frequently  of  advantage  in  diagnosis,  as  it 
may  be  said  that  epigastric  pain  promptly  relieved  by  anesthesin  and 
orthoform  indicates  a  lesion  of  the  gastric  mucosa.  The  anesthetic 
powder  does  no  good,  however,  in  cases  of  hypersecretion  unless  com- 
|?ined  with  sufficient  alkali  to  neutralize  the  excess  of  acid. 

The  effect  of  diet  on  the  pain  is  usually  well-marked — the  coarser 
the  food,  the  greater  the  severity  of  the  pain.  The  beneficial  effect 
of  a  milk  diet  is  universally  acknowledged. 

In  some  cases  food  taken  during  a  period  of  pain  aggravates  it,  but 
in  the  majority  of  cases,  the  ingestion  of  food  is  followed  by  a  certain 
degree  of  relief. 

In  rare  instances  the  pain  is  increased  by  exercise  to  a  marked 
degree.  This  pain  on  exertion  is  usually  due  to  an  extension  to  the 
peritoneum,  and  a  local  adhesive  peritonitis,  and  may  precede 
perforation. 

(jcnerally  speaking,  i)ain  in  acute  gastric  ulcer  falls  into  two  classes, 
according  to  whether  the  ulcer  is  at  or  near  the  pylorus,  whether  on 
the  stomach  or  duodenal  side,  or  is  at  a  j)nrt  of  the  stomach  away  from 
this  orifice. 

Ulcers  at  or  Near  the  Pylorus,  (lastric  or  DnihIokiI. — The  pain  is 
of  two  kinds.  In  one  variety  the  pain  is  of  a  burning,  sore,  or  gnawing 
character,  coming  one  to  three  hours  after  eating,  when  the  food  is 


ACUTE  aASTRIC   ULCER  111 

passing  through  the  pylorus,  and  is  due  to  the  local  irritation  of  the 
denuded  floor  of  the  ulcer.  This  form  of  pain  is  regularly  relieved 
by  eating.  Emesis  affords  relief  in  proportion  to  the  thoroughness  of 
the  act,  the  vomitus  consisting  of  recently  ingested  food,  often  diluted 
by  acid  fluid.  Anesthesin  and  orthoform  usually  afford  marked  relief 
at  the  time  of  pain.  This  form  of  pain  occurs  in  but  35  per  cent,  of 
the  acute  cases,  as  against  75  per  cent,  of  the  chronic  ulcers. 

The  second  variety  of  pain  in  ulcers  at  or  near  the  pylorus  is  of  a 
burning,  gnawing  character,  coming  about  one  hour  after  taking  food, 
and  lasting  until  the  stomach  is  emptied,  either  by  the  natural  passage 
of  chyme  through  the  pylorus,  or  by  emesis.  Eating  usually  gives  but 
slight  temporary  relief.  Anesthesin  and  orthoform  are  without  any 
marked  effect.  Temporary  relief  of  a  greater  or  less  degree  follows 
the  administration  of  alkalies,  granted  that  these  are  given  in  full 
doses.    This  form  of  pain  occurs  in  30  per  cent,  of  the  acute  cases. 

In  these  latter  cases  there  is  pyloric  spasm,  with  food  retention  and 
hypersecretion,  and  it  is  the  hypersecretion  that  occasions  the  pain. 
The  vomited  matters  are  liquid  in  character,  acid  in  reaction,  often 
excessively  so,  and  contain  food  remains  that  have  been  retained  in 
the  stomach  for  an  abnormal  period.  The  vomitus  is  often  of  a  brownish 
color  dependent  upon  altered  blood. 

In  many  of  these  cases  the  pain  is  not  severe,  but  is  described  as 
a  "lump,"  or  "oppression,"  or  "distress,"  coming  after  meals  and 
lasting  more  or  less  continuously  until  the  stomach  becomes  empty. 

A  typical  instance  is  the  following: 

G.  W.,  aged  forty-three  years.  For  five  days  he  had  complained  of 
a  sense  of  weight  and  oppression  in  the  stomach,  "like  a  lump,"  coming 
one  hour  after  meals  and  lasting  more  or  less  continuously^  throughout 
the  day,  though  temporarily  relieved  by  eating.  Physical  examination : 
Marked  epigastric  and  dorsal  points  of  tenderness.  Vomited  matters 
(induced  for  relief)  four  hours  after  eating  are  copious,  composed 
five-sixths  of  liquid  and  one-sixth  of  food  remains.  Total  acidity, 
54;  free  hydrochloric  acid,  12.     Blood  strongly  positive. 

It  is  quite  characteristic  of  these  cases  that  the  most  marked  distress 
occurs  during  the  early  part  of  the  night.  The  patient  will  eat  his 
dinner,  for  example,  at  seven  o'clock,  and  after  getting  in  bed  will 
complain  of  w^eight  and  oppression  amounting  finally  to  a  burning 
pain,  and  obtains  relief  only  after  vomiting. 

The  dift'erential  diagnosis  between  acute  gastric  ulcer  at  or  near 
the  pylorus  and  ulcer  in  the  duodenum  cannot  be  positi^'ely  made. 
Neither  can  acute  gastric  ulceration  be  differentiated  from  acute 
exacerbation  of  a  chronic  ulcer  that  hitherto  has  run  more  or  less 
a  quiescent  course. 


112  ACUTE  AND  CHRONIC  ULCER 

Ulcers  Not  Invohiug  the  Pylorus. — These  accord  more  with  the 
older  descriptions  of  gastric  ulcer  in  the  text-books.  The  pain  occurs 
soon  after  eating,  generally  between  one-quarter  and  one-half  hour. 
Pain  coming  at  once  after  eating  is  usually  of  esophageal  origin.  Pyloric 
spasm  and  hypersecretion  do  not  occur,  so  that  the  pain  is  not  so  con- 
tinuous, or  it  is  so  much  influenced  by  the  administration  of  alkalies. 
It  is  regularly  relieved  by  the  natural  or  artificial  empyting  of  the 
stomach,  and  by  anesthesin  and  orthoform.  Eating  during  the  period 
of  pain  almost  regularly  aggravates  it.  This  form  of  pain  occurred 
in  16  per  cent,  of  the  acute  cases  observed  by  the  writer. 

Nausea. — Nausea  in  gastric  ulcer  is  but  rarely  complained  of,  and 
the  appetite  is  generally  maintained  throughout  the  disease,  although 
many  of  the  patients  are  afraid  to  eat  because  of  the  succeeding  distress 
so  caused. 

Vomiting. — ^^^omiting  is  commonly  observed,  more  frequently  induced 
than  spontaneous.  The  characteristics  of  the  vomited  matters  have 
been  as  above  described,  and  may  be  summed  up  by  saying  that  in  ulcer 
at  or  near  the  pylorus,  vomiting  occurs  because  of  the  hypersecretion, 
while  in  ulcers  not  involving  the  pylorus,  vomiting  is  for  the  purpose 
of  ridding  the  stomach  of  the  food  that  is  irritating  the  ulcer. 

The  above  description  of  the  symptoms  of  acute  ulcer  apply  only 
to  those  observed  in  the  early  stages  of  the  disease,  and  they  will  be 
seen  to  be  somewhat  different  from  those  of  the  chronic  form.  Should 
the  ulcer  pass  into  the  chronic  stage,  through  medical  neglect  or  other- 
wise, the  symptoms  approach  more  and  more  those  of  the  chronic 
ulcer,  so  that  it  ma}'  be  impossible  to  say  in  any  given  case  whether 
there  is  an  acute  ulcer  becoming  chronic,  or  a  chronic  ulcer  during  a 
period  of  exacerbation. 

Hemorrhage,  perforation,  and  other  complications  of  acute  ulcer 
are  described,  together  with  those  of  the  chronic  form. 

Physical  Signs. — Physical  signs  of  acute  ulcer  are  usually  more 
evident  than  in  the  chronic  forms — the  epigastric  and  dorsal  points 
and  hyperesthetic  zones  being  especially  well-marked.  Detailed 
description   of  these  ])hysical   signs  are  given   later   (see  p.    139).    - 

Diagnosis. — Gastric  Analysis. — It  is  a  fundamental  rule  that  a  tube 
should  never  be  passed  if  acute  ulcer  of  the  stomach  is  suspected, 
owing  to  the  danger  of  lieniorrhage  or  i)erf()ration.  For  this  reason 
there  are  few  data  obtainable  as  to  gastric  secretions  in  acute  ulcer. 
It  is  only  in  the  atypical  cases  in  which  gastric  analyses  are  made  before 
the  diagnosis  of  acute  ulcer  is  susi)ected  that  we  have  any  knowledge 
of  conditions  of  acidity  and  secretion.  In  the  majority  of  cases  the 
test  breakfast  affords  no  clue.  In  a  certain  number  of  instances, 
however,  the  tube  withdraws  an  excess  of  Ii(|ui(l  secretion  more  or 


CHRONIC   ULCER  OF  THE  STOMACH  Il3 

less  mixed  with  altered  blood  and  containing  nsually  food  remains 
that  have  been  retained  an  abnormal  time  in  the  stomach.  The  acidity 
in  these  cases  is  not  usually  far  from  normal,  and  may  even  be  sub- 
normal, especially  if  much  blood  be  present  (see  table,  p.  136).  These 
are  the  cases  of  acute  ulcer  near  the  pylorus,  with  spasm  of  that  orifice 
and  hypersecretion.  In  other  instances  the  test  breakfast  is  normal 
as  regards  secretion  and  acidity,  although  the  presence  of  altered  blood 
may  afford  a  clue  to  the  diagnosis.  Much  can  be  learned  from  an 
examination  of  the  vomited  matters,  as  may  be  inferred  from  what 
has  already  been  said  under  the  heading  of  pain  and  vomiiing.  The 
acidity  is  rarely  increased. 

Gastric  acidity  is,  however,  influenced  by  gastric  hemorrhage.  Of 
19  cases  examined  by  Fenwick  one  month  after  hematemesis,  free 
hydrochloric  acid  was  absent  in  17,  while  in  the  other  2  only  traces 
could  be  found.  This  condition  of  low  acidity  persists  until  the  patient 
is  well  over  the  loss  of  blood,  and  it  may  well  be  that  many  of  the 
vague  symptoms  of  indigestion  that  often  follow  the  cure  of  acute 
gastric  ulcer  are  due  to  this  lack  of  hydrochloric  acid  in  the  stomach. 

Recurrences. — Recurrences  are  common.  Twenty  per  cent,  of 
Fenwick's  cases  were  readmitted  within  three  years.  These  recur- 
rences are  to  be  distinguished  from  the  recrudescences  of  the  chronic 
form  by  the  fact  that  in  the  interval  the  patients  are  more  completely 
free  from  symptoms  in  the  acute  than  in  the  chronic  form,  in  which  a 
careful  history  will  bring  out  more  or  less  gastric  discomfort  between 
the  exacerbations. 

Sequelae. — Acute  ulcer  of  the  stomach  usually  heals  quickly  without 
untoward  results,  although  there  is  a  tendency  for  the  ulcer  to  become 
chronic.  This  tendency  is  increased  by  lack  of  appropriate  care  and 
diet  during  the  acute  stages.  Acute  ulcers  with  hemorrhage  seldom 
pass  into  the  chronic  form,  because  of  the  enforced  medical  care  necessi- 
tated by  this  alarming  symptom. 


CHRONIC    ULCER    OF    THE    STOMACH 

The  clinical  course  of  chronic  gastric  ulcer  may  be  subdivided  into 
four  groups: 

1.  Classical  pain  type. 

2.  Irregular  pain  type. 

3.  Vomiting  type. 

4.  Hypersecretion  type. 

I.  Symptoms  in  Classical  Pain  Type. — The  most  definite  and  charac- 
teristic symptom  of  chronic  ulcer  is  a  pain  variously  described  as 


114 


ACUTE  AND  CHRONIC   ULCER 


burning,  boring,  drawing,  gnawing,  cramp-like,  or  neuralgic,  or  the 
feeling  of  a  painful  lump  or  pressure,  occurring  two  to  four  hours  after 
a  meal,  and  lasting  until  the  patient  eats  again.  It  has  been  described 
as  "  hunger  pain."  This  pain  was  first  accurately  described  by  John 
Abercrombie  in  1S30,  who  wrote:  "The  leading  peculiarity  of  disease 
of  the  duodenum,  as  far  as  we  are  at  present  acquainted  with  it,  seems 
to  be  that  the  food  is  taken  with  relish,  and  the  first  stage  of  digestion 
is  not  impeded ;  but  that  the  pain  begins  about  the  time  when  the  food 
is  passing  out  of  the  stomach,  or  from  two  to  four  hours  after  a  meal." 

It  is  not  the  kind  of  pain,  or  the  localization  of  the  pain,  that  is  dis- 
tinctive, but  the  time  of  the  pain,  and  the  relief  afforded  by  eating. 

In  many  gastric  disorders  pain  appears  when  the  stomach  is  full — 
in  ulcer,  the  characteristic  pain  begins  when  the  stomach  begins  to 
empty  itself  and  to  force  its  acid  contents  through  the  pyloric  orifice. 
The  pain  may  be  referred  to  the  epigastrium,  left  inguinal  region,  or 
to  the  back,  more  rarely  to  one  or  the  other  hypochondrium  or  to  the 


Fig.   24 


Classical  ulcer  pain.  The  vertical  (lotted  liiie.s  indicate  hours.  The  three  circles,  B,  L,  and  D,  indicate 
breakfast,  lunch,  and  dinner.  The  time  of  retiring  is  indicated  by  the  outline  of  the  bed.  The  mark 
X  in  this  and  in  succeeding  charts  indicates  extra  nourishment. 


unbilical  region.  The  location  of  the  pain  bears  no  definite  relation 
to  the  position  of  the  ulcer.  The  most  that  can  be  said  is  that  in  ulcera- 
tion of  the  duodenum,  i)ain  is  often  experienced  to  the  right  of  the 
median  line.  This  pain  in  the  writer's  exjjerience  has  occurred  in 
75  per  cent,  of  his  ulcer  cases.  One  great  characteristic  of  the  pain 
is  its  recurrence  at  a  definite  time  after  eating  in  each  patient.  The 
time  may  not  be  the  same  for  all  patients,  but  each  one  has  a  definite 
hour  at  which  his  pain  comes  on,  and  this  interval  for  him  is  fixed. 
There  is  a  definite  sequence  in  the  time  of  eating  and  in  the  appearance 
of  the  pain  which  is  very  characteristic. 

Another  characteristic  of  the  pain  is  the  fact  that  the  larger  the 
meal,  the  longer  the  period  of  relief;  pain  may  occur  one  or  two  hours 
after  l)reakfast  and  Imirh,  but  is  dcfcrnMl  for  two  or  three  hours  after 
a  hearty  dinner. 

We  must  sharply  discriminate  between  distress,  uneasiness,  or  dis- 
comfort on  the  one  hand,  and  actual  pain  on  the  other.     The  former 


CHRONIC   ULCER  OF   THE  STOMACH  115 

may  occur  from  a  great  variety  of  causes,  but  the  latter,  epigastric 
pain,  while  occurring  occasionally  and  temporarily  as  the  result  of 
gross  diet  indiscretions,  especially  in  children,  does  not  recur  day 
after  day  without  an  organic  cause.  Recurring  eingastralgia  of  a  purely 
functional  nature  does  not  occur — the  lesion  may  not  be  in  the  stomach, 
it  may  be  an  appendix  or  a  gall-bladder,  but  there  is  a  lesion  some- 
where. A  "gone  feeling"  in  the  fasting  state  is  not  uncommon  as  a 
neurosis,  but  actual  pain  at  this  time  comes  only  from  an  organic 
cause.  The  "painful  sense  of  stomach  emptiness"  or  the  gastralgo- 
kenosis  of  Boas  does  not  exist  as  a  pure  neurosis.  A  great  deal  has 
been  written  about  the  pain  of  hyperacidity.  There  is  no  evidence 
to  prove  that  the  intact  mucous  membrane  of  the  stomach  is  at  all 
sensitive  to  acid  stimulation — in  fact  from  experimental  and  clinical 
evidence  it  seems  fair  to  assume  that  hyperacidity  as  such,  does  not 
produce  painful  sensations  in  the  human  stomach,  even  if  there  be 
abrasions  of  the  mucous  membrane. 

The  history  of  pain  of  ulcer  may  extend  over  years,  either  steadily, 
or  more  usually  with  periods  of  comparative  freedom.  A  close  cross- 
examination  will,  however,  nearly  always  bring  out  the  fact  that  even 
in  these  remissions,  minor  symptoms  are  present  and  the  patient's 
stomach  never  feels  entirely  comfortable. 

Recurrences  of  gastric  ulcer  are  most  apt  to  occur  during  the  cold, 
winter  months.  In  summer  the  symptoms  are  almost  regularly  milder 
in  severity,  or  even  absent. 

There  are  milder  cases  of  ulcer  in  which  the  sensation  does  not  amount 
to  actual  pain,  but  to  discomfort  or  uneasiness  appearing  two  to  four 
hours  after  meals.  If  we  have  a  patient  without  gastroptosis,  gall- 
bladder disease,  or  chronic  appendicitis,  who  complains  of  constantly 
recurring  distress  two  or  three  hours  after  meals,  relieved  by  eating, 
we  may  reasonably  affirm  the  presence  of  gastric  or  duodenal  ulcer, 
especially  if  continuous  or  alimentary  hypersecretion  be  present. 

The  quality  of  food,  while  making  a  great  difference  in  the  intensity 
of  the  pain  of  acute  ulcer,  seems  to  exert  very  little  difference  in  that 
of  the  chronic  variety.  It  is  otherwise  with  the  quantity  of  the  food 
— the  larger  the  meal  the  longer  the  period  of  freedom  from  pain  or 
distress  that  follow^s.  Dinner  is  the  most  comfortable  meal,  the 
middle  of  the  night  the  most  distressing  time.  The  writer  has  found 
that  the  pain  seems  to  depend  upon  the  degree  of  gastric  acidity  and 
hypersecretion,  and  after  analyzing  the  results  of  the  examination  of 
fasting  stomachs  and  test  breakfasts  in  chronic  ulcer,  has  arrived  at 
the  following  conclusions: 

1.  Those  patients  with  ulcer  who  have  the  classical  pain,  have  high 
acidity  and  an  alimentar}-  hypersecretion. 


116  ACUTE  AND  CHRONIC  ULCER 

2.  Those  with  "discomfort"  have  less  acidity  and  less  alimentary 
hypersecretion. 

3.  Those  with  slight  and  irregular  pains  are  apt  to  have  neither 
high  acidity  nor  alimentary  hypersecretion. 

4.  In  those  patients  with  undoubted  ulcer  who  have  severe  pains, 
with  an  acidity  not  above  the  normal,  complications,  such  as  adhe- 
sions, are  apt  to  be  present. 

It  seems  to  the  writer  that  the  pain  of  ulcer  depends  upon  the  exces- 
sive amount  of  gastric  juice  of  high  acidity,  and  not  directly  upon  the 
nature  of  the  food  itself.  It  is  upon  the  reduction  of  this  high  acidity 
that  the  whole  medical  treatment  depends. 

According  to  Moynihan,  it  is  a  simple  thing  to  differentiate  a  gastric 
ulcer  from  one  in  the  duodenum:  If  pain  occur  one  or  two  hours  after 
meals,  the  ulcer  is  gastric;  if  pain  occur  three  or  four  hours  after  meals, 
the  ulcer  is  duodenal;  if  pain  occur  one  or  two  hours  after  meals  and 
then  subsides,  only  to  increase  in  intensity  one  or  two  hours  later, 
the  patient  has  two  ulcers,  one  in  the  stomach  and  one  in  the  duodenum. 

These  rules  for  localization  have  not  seemed  accurate  in  the  writer's 
experience,  and  he  can  admit  only  that  pain  occurring  two  to  four 
hours  after  meals  indicates  an  ulcer  near  the  pylorus,  either  on  the 
gastric  or  on  the  duodenal  side.  A  more  accurate  localization  than 
this  does  not  seem  possible. 

In  ulcer  a  history  of  gaseous  attacks  may  be  quite  as  characteristic 
as  the  pain,  usually  running  a  course  parallel  to  that  of  the  pain,  appear- 
ing when  the  ulcer  pain  is  at  its  height.  The  greater  the  acidity  the 
greater  is  usually  the  distress  from  gas.  The  measures  which  relieve 
the  pain — food,  drink,  alkalies,  and  vomiting — also  serve  to  mitigate 
the  severity  of  the  distention. 

Differential  Diagnosis  of  Ulcer  Pain. — Chronic  Appendicitis. — In 
chronic  aj^pendicitis  pain  rcferrerl  to  the  epigastrium  may  come  after 
food,  sometimes  earlier  and  sometimes  later,  but  usually  without  the 
regularity  observed  in  ulcer.  In  some  cases,  however,  a  definite  regu- 
larity can  be  observed,  the  pain  coming  at  a  fixed  and  definite  time 
after  meals.  It  may  be  relieved  temporarily  by  eating,  as  is  the  case 
with  gastric  ulcer,  and  is  usually  worse  after  exercise.  As  it  is,  on  the 
other  hand  usually  relieved  by  rest,  an  ulcer  cure  with  bed  treatment, 
is  often  followed  by  marked  improvement.  Twelve  per  cent,  of  the 
writer's  earlier  cases  of  sui)pos('d  chronic  ulcer  turned  out  to  be  cases 
of  chronic  appendicitis  with  gastric  symptoms  -they  were  "improved" 
after  an  ulcer  cure.  i)ut  the  symptoms  ceased  only  after  removal  of 
the  ai)pciidix.  K])igastric  tenderness  may  be  observed.  Pressure 
over  the  appendix  is  not  painful  in  many  of  the  cases.  Hyperacidity 
and  hypersecretion  may  occur  with  chronic  appendicitis  as  well  as 


CHRONIC   ULCER  OF  THE  STOMACH  117 

with  ulcer,  so  that  a  differential  diagnosis,  by  gastric  analysis  alone,  is 
not  usually  possible. 

It  is  of  importance  to  remember  that  in  appendicular  dyspepsia 
hematemesis  may  occur.  In  over  a  dozen  cases  seen  by  Moynihan, 
in  which  no  ulcer  was  found  at  operation,  but  in  which  a  cure  was 
effected  by  the  removal  of  the  appendix,  hemorrhage  from  the  stomach 
had  exceeded  a  pint  at  one  time.  The  cause  for  the  hematemesis  is 
not  well  understood,  but  it  is  probably  due  to  pore-like  erosions. 
Moynihan's  observations,  made  on  these  cases  of  chronic  appendicitis 
giving  gastric  symptoms,  are  most  interesting.  He  has  noted  at  the 
time  of  operation  that  from  time  to  time  there  is  a  condition  of  vigor- 
ous contraction  involving  the  pylorus  and  the  pyloric  antrum,  the 
affected  area  becoming  thickened,  contracted,  and  pale.  It  would 
seem  as  if  the  pylorus  served  as  a  guard  to  the  bowel  distal  to  it,  and 
that  in  inflammatory  and  irritative  conditions  its  protective  control 
extended  to  the  whole  of  the  midgut.  To  show  how  close  may  be 
the  mimicry  of  the  two  diseases,  even  to  the  symptoms  of  perforation, 
reference  should  be  made  to  the  clinical  history  of  a  case  of  chronic 
appendicitis  with  epigastric  pain  and  perforative  symptoms  narrated 
under  the  heading  of  Chronic  Appendicitis  (p.  571). 

Arterial  Sclerosis. — Arterial  sclerosis  may  give  rise  to  epigastric 
pain  occurring  after  meals,  and  may  closely  simulate  that  due  to 
ulcer.  The  pain  or,  as  is  more  usual,  the  feeling  of  discomfort,  usually 
appears  earlier  than  in  ulcer,  being  most  marked  at  the  height  of 
gastric  activity,  when  the  demand  is  made  for  an  increased  blood 
supply  for  the  physiological  processes  of  digestion.  It  is  suggestive 
of  the  arteriosclerotic  origin  of  the  pain  that  it  does  not  usually  occur 
when  the  patient  sits  or  lies  down  after  eating,  but  regularly  appears 
if  exercise  is  indulged  in  after  a  full  meal.  In  almost  all  of  these  cases 
flatulence  is  marked,  and  relief  from  the  distress  follows  free  eructa- 
tions. This  is  rarely  observed  with  ulcer.  Anginoid  symptoms  occur- 
ring spontaneously  or  after  exertion  are  of  frequent  occurrence,  and 
are  of  material  help  in  diagnosis. 

Diseases  of  the  Gall-bladder. — Diseases  of  the  gall-bladder  may  give 
rise  to  pain  closely  resembling  that  of  ulcer.  The  regularity  of  the 
pain  is,  however,  not  as  marked  as  in  ulcer,  appearing  "at  any  time," 
without  being  influenced  by  the  kind  of  food  that  is  taken.  Marked 
variations  occur  from  day  to  day,  and  there  are  frequent  periods 
during  which  the  pain  is  more  or  less  constant,  associated  with  tender- 
ness limited  to  the  gall-bladder  region,  usually  associated  with  localized 
rigidity  of  the  right  costal  arch  and  of  the  upper  portion  of  the  right 
rectus.  Hyperacidity  occurs  in  only  30  per  cent,  of  cases,  many  cases 
showing  subacidity  or  achylia. 


118  ACUTE  AND  CHRONIC   ULCER 

The  diagnosis  is  usually  made  without  much  difficulty.  In  other 
cases  no  definite  opinion  can  be  expressed,  and  the  uncertainty'  in 
diagnosis  is  increased  by  the  fact  that  cholecystitis  and  gastric  or 
duodenal  ulcer  often  occur  together  in  the  same  patient.  Adhesions 
between  the  gall-bladder  and  the  pyloric  region  of  the  stomach  may  give 
rise  to  dragging  pains  whenever  they  are  stretched  by  the  mechanical 
presence  of  food  and  cause  pain  or  discomfort  during  the  digestive 
period.  These  pains  are  increased  by  exercise  and  are  relieved  by 
physical  rest. 

Patients  who  habitually  bolt  their  food  without  masticating  and 
especially  those  with  defective  teeth,  are  very  apt  to  suffer  from  epi- 
gastric pain  after  a  meal.  The  distress  occurs  only  after  the  taking 
of  solid  food,  and  ceases  when  liquid  food  is  enjoined,  or  when  the 
patients  follow  instructions  as  to  the  proper  methods  of  eating. 

II.  Symptoms  in  Irregular  Pain  Type. — Pain  in  Left  Inguinal  Region. 
— A  small  number  of  i)atients,  amounting  to  o  per  cent,  of  the  writer's 
cases,  refer  their  pain  to  the  left  inguinal  region,  the  pain  coming  two 
to  four  hours  after  meals,  relieved  by  eating  and  uninfluenced  by  the 
condition  of  the  bowels.  In  two  of  the  cases  operation  showed  the 
ulcer  to  be  on  the  posterior  wall  near  the  cardiac  orifice. 

The  following  is  the  history  of  one  of  these  patients: 

G.  McL.,  aged  forty-two  years,  for  twenty  years  has  suffered  from 
sharp  localized  pain  in  the  left  inguinal  region,  uninfluenced  by  defeca- 
tion, coming  two  to  four  hours  after  eating,  and  relieved  only  by  eating' 
again.  There  have  been  many  periods  of  intermission,  but  the  character 
of  the  pain  when  it  occurs  is  always  the  same.  From  time  to  time  he 
vomits  acid  scalding  fluid.  At  no  time  has  he  ever  had  pain  in  his 
epigastrium. 

Physical  Examination. — Localized  tenderness  in  ei)igastrium;  no 
dorsal  point.    Sigmoid  normal.    Xo  evidence  of  renal  calculus. 

(Jcistrir  Analysis. — Fasting  stomach:  80  c.c,  fluid,  with  a  few  starchy 
remains;  total  acidity,  30;  free  hydrochloric  acid,  1(). 

Test  Breakfast. — .30  c.c,  pasty  consistency;  some  gastric  mucus. 
Total  acidity,  ()S;  free  hydrochloric  acid,  .34.  The  j)ain  was  so  severe 
and  uninfluenced  by  medical  treatment  that  operative  interference 
was  resorted  to,  and  an  ulcer  the  size  of  a  fifty-cent  piece  was  found 
in  the  lesser  curxature  of  the  posterior  wall  near  the  cardia.  This  was 
ex.sected. 

Recovery  was  slow,  nausea,  vomiting,  an<l  ])ain  remaining. 

A  gastro-enterostomy  was  done  four  weeks  later,  and  since  that 
time  the  jjatient  has  remaiiic  1  in  perfect  health,  without  a  trace  of 
pain  or  discomfort.  The  classical  time  at  which  the  pain  occurred, 
and  its  relief  by  eating,  are  interesting  and  instructive  features. 


CHRONIC   ULCER  OF  THE  STOMACH  119 

Pain  in  the  Back. — This  is  frequently  associated  with  the  epigastric 
pain,  but  it  may  occur  as  a  solitary  point  of  localization. 

(a)  It  usually  ajjpears  two  or  three  hours  after  eating,  and  is  relieved 
by  food.  Indicating  an  ulcer  on  the  posterior  wall,  physical  signs  are 
usually  lacking,  and  there  is  not  apt  to  be  hyperacidity.  In  the  writer's 
experience  this  back  pain  is  often  a  precursor  of  perforation. 

T.  H.  S.,  aged  twenty-eight  years.  Patient  was  practically  free 
from  indigestion  until  two  weeks  ago,  when  he  began  to  complain  of  a 
disagreeable  pressure  feeling  in  the  epigastrium  which  merges  gradually 
into  an  intense  pain  in  the  middle  of  the  back.  His  symptoms  are  at 
once  relieved  by  eating,  and  do  not  reappear  for  several  hours  after 
his  meal. 

Patient  w^as  placed  on  ulcer  cure.  On  tenth  day  symptoms  of  sub- 
acute perforation  occurred,  complicated  by  empyema.  Recovery  slow 
but  eventually  complete. 

(6)  Pain  in  the  back,  of  a  steady,  boring  character,  without  the 
relief  afforded  by  eating,  often  severe  enough  to  necessitate  occasional 
doses  of  morphine,  suggest  adhesions  to  and  probably  erosion  of  the 
pancreas.    Such  a  case  is  the  following: 

M.  B.,  aged  forty-three  years.  Formerly  a  heavy  drinker,  but  has 
been  abstinent  for  over  ten  years.  One  year  ago  began  to  complain 
of  severe  pain  beginning  in  the  epigastrium  and  running  through  to 
the  back,  coming  three  or  four  hours  after  eating,  and  lasting  until  he 
ate  again.  For  the  past  three  weeks  he  has  suffered  from  a  steady, 
boring  pain  in  his  back,  not  influenced  by  eating.  This  pain  has  been 
so  steady  and  severe  that  he  has  been  kept  more  or  less  under  morphine 
the  greater  part  of  the  time. 

Physical  examination  shows  tenderness  to  the  right  of  the  median 
line,  one  inch  above  the  navel. 

Gastric  Analysis. — Fasting,  negative.  Test  breakfast:  10  c.c, 
watery,  scanty  food  remains  of  roll.  Total  acidity,  30;  free  hydro- 
chloric acid,  20.  Operation  shows  ulcer  on  posterior  wall,  perforating 
into  pancreas,  and  causing  a  well-marked  erosion  of  the  pancreas  at 
this  point. 

Exsection,  suture  of  pancreas.  Gastro-enterostomy.  Perfect  res- 
toration to  health. 

Pain  Due  to  Adhesions. — According  to  Drummond,^  pain  between 
1  and  2  a.m.  almost  always  is  due  to  ulcer  that  is  adherent  to  the 
pancreas.     This  cannot  be  verified  by  the  writer. 

Pain  at  once  after  eating,  depending  for  its  intensity  upon  the 
mechanical  weight  of  the  ingested  food,  suggests  perigastric  adhesion. 

1  British  Modical  Journal,  July  10,  1909. 


120  ACUTE  AND  CHRONIC   ULCER 

Constant  pain  during  the  day  and  diminishing  during  the  latter 
part  of  the  night  is  also  seen  in  ulcers  of  the  lesser  curvature  near  the 
cardiac  orifice  with  adhesions. 

Pain  in  the  right  shoulder  after  exercise  or  after  meals  indicates 
adhesion  between  the  ulcer  and  the  liver. 

Pain  after  Ingestion  of  Food. — There  is  a  type  of  ulcer  near  the 
cardiac  end  in  which  pain  occurs  soon  after  the  ingestion  of  food, 
and  continues  until  the  stomach  empties  itself.  Hyperacidity  and 
hypersecretion  are  not  present. 

Two  i)eculiar  features  may  be  observed  in  these  cases:  (1)  There 
is  a  marked  intolerance  for  hot  food  or  drink.  The  patient  will  sip  a 
little  soup  and  almost  before  the  hot  liquid  has  had  time  to  reach  the 
stomach  will  gulp  down  two  or  three  swallows  of  iced  water  with 
instant  relief  to  the  burning.  Wines,  especially  Port,  Madeira,  and 
Sherry,  will  often  produce  the  same  instantaneous  burning  pain.  (2) 
The  patient  may  be  perfectly  free  from  all  symptoms  during  the 
day,  but  on  going  to  bed  at  night  the  pain  at  once  comes  on  and 
remains  until  some  alkaline  food  is  drunk,  after  which  there  is 
instant  relief.  The  pain  may  be  brought  on  again  by.  turning  on  the 
left  side.  There  is  no  pain  or  discomfort  in  these  cases  when  the 
stomach  is  empty. 

It  may  be  that  these  cases  cannot  be  easily  distinguished  from 
gouty  hyperesthesia  of  the  throat  and  esophagus.  In  the  gouty  cases 
the  hyperesthesia  is  diffused,  extending  from  the  pharynx  downward, 
the  whole  passages  being  sensitive  to  the  insertion  of  a  stomach-tube. 
Throat  symptoms  are  prominent  both  subjectively  and  objectively. 
The  gouty  cases  are,  furthermore,  aggravated  by  ulcer  treatment, 
and  improved  rather  by  fresh  air  and  exercise. 

Pain  during  Deglutition. — It  may  infrequently  happen  that  an  ulcer 
due  to  peptic  erosion  involves  the  lowest  segment  of  the  esophagus 
just  above  the  cardiac  orifice.  In  all  characteristics  it  is  the  same  as 
if  of  gastric  origin.  Pain  is  noted  as  occurring  during  the  act  of  deglu- 
tition— the  passage  of  a  tube  is  painful.  These  symi)toms  can  as  well 
occur  in  ulcers  just  distal  to  the  cardia,  so  that  a  ditt'erential  diagnosis 
may  be  impossible  except  bj^  the  use  of  the  esophagoscope.  This 
latter  method  of  diagnosis  is,  however,  so  dangerous  in  these  cases  as 
to  be  absolutely  unjustifiable. 

There  are  occasionally  radiations  f)f  the  j^ain  in  true  gastric  ulcer, 
so  as  to  be  experienced  with  greatest  intensity  at  the  level  of  the  ui)per 
I)ortion  of  the  esophagus,  but  Ewald,  in  describing  these  cases,  lays 
cini)liasis  on  the  fact  that  the  ])assage  of  a  tube  is  not  painful,  thus 
rendering  inij^robable  the  esoi)hageal  imi)licati()n  of  the  lesion.  Such 
a  radiation  upward  of  the  pain  of  gastric  ulcer  has  not  occurred  in 


CHRONIC   ULCER  OF  THE  STOMACH  121 

any  of  the  writer's  cases.  Cardiospasm  may  follow,  even  after  complete 
healing  of  an  nicer  of  the  cardia  without  cicatricial  contraction. 

Pain  Due  to  Reverse  Peristalsis. — There  is  a  peculiar  type  of  pain 
referred  to  the  cardia,  which  may  occur  even  if  the  lesion  be  pyloric 
or  duodenal.  This  pain  comes  in  waves  of  a  few  moments'  duration, 
of  a  distressing  character,  and  gradually  recedes,  or  else  is  suddenly 
and  completely  relieved  if  gas  or  sour  eructations  be  raised.  These 
waves  of  pain  recur  until  the  stomach  is  emptied  naturally  or  by 
emesis,  or  until  sufficient  alkalies  are  given.  The  cause  for  this  pain 
is  pyloric  spasm,  hyperacidity,  and  hypersecretion,  followed  by  reverse 
peristalsis. 

Constant  Gnawing  Pain. — Constant  gnawing  pain  uninfluenced  by 
food,  coming  in  attacks,  occurs  in  a  fairly  large  percentage  of  cases. 
The  attacks  may  last  a  few  days  or  a  few  wrecks,  and  are  followed  by 
periods  of  comparative  freedom,  although  in  these  free  intervals  a 
history  of  some  degree  of  pain  or  distress  may  usually  be  elicited. 

The  cause  for  the  constancy  of  the  pain  is  often  difficult  to 
determine,  although  in  the  main  the  cases  may  be  divided  into  two 
groups. 

In  the  first  group  the  pain  is  evidently  due  to  adhesions  or  erosions 
of  adjacent  viscera,  and  usually  indicates  an  acute  extension  of  the 
ulcer.  It  often  precedes  perforation  or  ulcer.  Such  a  history  is  as 
follows : 

F.  B.,  aged  fifty  years,  for  five  years  has  complained  of  pain  in 
the  left  iliac  fossa,  coming  two  or  three  hours  after  eating,  lasting  until 
the  next  meal.  Has  had  intermissions  of  two  or  three  months  at  a 
time.  Has  had  frequent  attacks  of  constant  severe  gastric  pain, 
uninfluenced  by  eating,  and  necessitating  the  use  of  morphine.  These 
attacks  last  usually  two  or  three  weeks,  and  are  not  accompanied  by 
nausea  or  vomiting. 

On  operation  an  ulcer  was  found  in  the  lesser  curvature  and  posterior 
wall,  near  the  cardia,  with  extensive  adhesions  to  the  pancreas. 

It  is  interesting  to  note  the  association  of  the  pain  in  the  left  iliac 
fossa  and  the  location  of  the  ulcer. 

In  the  second  group  are  placed  those  cases  of  constant  pain  due  to 
acute  exacerbations  of  a  chronic  ulcer,  especially  if  near  the  pylorus, 
causing  a  sudden  partial  closure  of  the  pyloric  opening,  either  from 
tumefaction  or  from  spasm.  As  the  result  of  the  pyloric  closure,  acute 
hypersecretion  occurs,  and  it  is  from  the  continual  irritation  of  the 
ulcer  by  the  continuous  acid  secretion  that  the  constant  pain  originates. 
This  pain  is  often  relieved  by  eating  or  by  taking  soda,  but  the  relief 
thus  afforded  is  incomplete  and  temporary.  IMore  marked  relief 
follows  emesis,  the  vomitus  consisting  of  large  quantities  of  acid  fluid. 


122  ACUTE  AND  CHRONIC  ULCER 

which  may  or  may  not  contain  l)lood.  In  severe  cases  acetonemia  is 
present. 

These  hypersecretion  cases  will  be  discussed  more  in  detail  under  a 
separate  headin*;. 

III.  Symptoms  in  Vomiting  Type. — There  is  a  distinct  type  of  chronic 
ulcer  characterized  hy  recurring  attacks  of  nausea  and  vomiting,  with 
periods  of  complete  freedom.  The  vomited  matters  consist  only  of 
what  has  been  recently  eaten,  never  of  acid  fluid  or  residual  food;  the 
stomach  simply  rejects  what  has  been  put  into  it.  Acute  gastritis  is 
the  diagnosis  usually  made,  but  the  attacks  are  more  prolonged  than 
in  simple  gastritis,  frequently  lasting  seven  to  ten  days. 

The  patient  experiences  a  sense  of  weight  or  oppression  one-half  to 
to  two  hours  after  eating,  followed  by  nausea  and  vomiting.  There  may 
be  severe  retching  after  the  stomach  has  been  emptied.  In  other 
cases  the  vomiting  is  erratic  as  to  time,  and  absolutely  without  relation 
to  the  taking  of  food. 

The  characteristics  then  of  this  group  are:  (1)  Prolonged  irritability 
of  the  stomach  to  retained  food.  (2)  Negative  character  of  the  vomited 
matters.  These  are  not  sufficiently  characteristic  to  enable  one  to  be 
positive  about  the  diagnosis,  but  chronic  ulcer  may  be  suspected  in 
any  case  of  recurring  vomiting  of  recently  ingested  food,  lasting  longer 
than  three  days,  that  is  not  due  to  gall-bladder  disease  or  to  appendi- 
citis. At  any  time  more  characteristic  symptoms  of  ulcer  may  appear. 
Such  a  history  is  as  follows: 

S.  S.,  aged  thirty-eight  years,  has  been  accustomed  to  take  three  to 
five  cups  of  strong  tea  a  day,  and  to  eat  between  meals.  Alcohol 
denied.  Bowels  always  constipated.  For  six  years  has  been  subject 
to  occasional  attacks  of  indigestion  following  indiscretions  in  diet^ — 
weight  in  the  stomach,  heart-burn,  and  the  belching  of  gas.  There  was 
no  pain  or  tenderness,  and  until  a  year  ago  there  was  no  nausea  or 
vomiting.  One  year  ago,  during  one  of  these  attacks,  she  developed 
gastric  irritability  so  that  for  a  number  of  days  she  was  quite  unable 
to  retain  any  food.  The  vomited  matters  consisted  merely  of  what 
she  had  recently  eaten. 

From  this  attack  she  recovered  and  for  three  months  was  able  to 
eat  all  sorts  of  food  without  discomfort. 

Eight  months  ago  she  had  a  similar  attack,  though  more  severe, 
lasting  two  weeks.    She  was  then  well  for  four  months. 

Three  and  a  half  months  ago  she  again  had  an  acute  outbreak;  she 
sufl'erf'd  from  frecpient  attacks  of  nausea  and  vomiting,  although 
without  any  definite  relation  to  the  taking  of  food.  She  left  off  one 
article  of  diet  after  another,  being  finally  reduced  to  zoolak  and  oat- 
meal gruel,  losing  constantly  in  flesh  and  strength,  and  spending  most 


CHRONIC   ULCER  OF  THE  STOMACH  123 

of  her  time  in  bed.  Two  weeks  ago  her  nausea  and  vomiting  became 
worse  and  she  has  retained  very  little  on  her  stomach  since  that  time. 
At  no  time  has  there  been  vomiting  of  blood,  melena,  pain  or  tenderness. 

On  admission  physical  examination  was  entirely  negative  except 
for  marked  atony  of  the  ascending  colon. 

Gastric  Analysis. — Fasting  stomach,  50  c.c,  greenish  fluid,  without 
food  remains.  Total  acidity,  54;  free  hydrochloric  acid,  6.  Blood 
negative.    Weak  erythrodextrin  reaction. 

Test  Breakfast:  40  c.c,  well  digested.  Total  acidity,  90;  free  hydro- 
chloric acid,  70. 

During  the  first  week  of  treatment  she  vomited  once  every  day 
without  relation  to  meals,  but  never  at  a  time  when  the  stomach 
should  normally  be  empty.  After  the  first  week  she  w^as  up  and  around, 
eating  everything  and  complaining  of  no  gastric  discomfort  whatever. 

Readmission. — She  was  readmitted  to  the  hospital  four  weeks  later 
with  the  following  history: 

After  the  patient  left  the  hospital  she  remained  free  of  distress, 
though  she  was  quite  weak.    She  ate  plain  food  with  relish. 

Two  weeks  ago  without  any  evident  cause  she  was  suddenly  seized 
with  severe  vomiting  and  intense,  stinging  pain  in  the  epigastrium. 
The  vomitus  was  thin  and  copious.  The  pain  was  partially  allayed 
for  a  time  by  eating,  but  ceased  entirely  only  after  free  emesis.  These 
symptoms  had  continued  for  the  past  two  weeks  without  amelioration. 

Physical  Examination. — The  patient  was  weak  and  emaciated, 
evidently  suffering  acute  pain.  There  is  frequent  vomiting  of  food 
and  acid  water  without  admixture  of  blood.  Abdomen  retracted  and 
scaphoid,  but  is  everywhere  insensitive.  No  dorsal  point.  Lower 
curvature  4  cm.  above  the  umbilicus. 

Examination  of  Vomitus. — 30  ounces  of  browniish,  turbid  fluid  with 
a  finely  divided,  brownish  black  sediment.  Blood  positive.  Total 
acidity,  80;  free  hydrochloric  acid,  48. 

Microscopical  examination  shows  a  few  undigested  starch  cells, 
much  brownish  granula  detritus  of  altered  blood.  No  sarcinae  or 
bacilli. 

Patient  was  at  once  put  on  the  von  Leube  ulcer  treatment  with 
atropine  administered  hypodermically.  In  spite  of  this  treatment, 
however,  she  continued  to  have  pain  and  to  vomit  brown  acid  fluid 
giving  positive  blood  reactions.  This  often  amounted  to  over  three 
pints  in  the  twenty-four  hours. 

On  the  twenty-second  day  of  treatment  she  had  a  severe  hematemesis 
and  passed  tarry  stools.    She  was  rallied  only  with  extreme  difficulty. 

All  medical  efforts  failing  to  relieve  her  condition,  gastro-enterostomy 
was  performed.    The  pylorus  was  found  to  be  much  thickened  by  an 


124 


ACUTE  AND  CHRONIC   ULCER 


old  ulcer  causing  well-marked  pyloric  stenosis.  The  thickness  of  the 
ulcer  base  indicated  that  the  lesion  must  have  existed  for  months,  more 
jjrohahly  for  years.    There  were  no  adhesions. 

IV.  Symptoms  in  Hypersecretion  Type. — The  subject  of  hypersecre- 
tion is  elsewhere  discussed.  Under  the  present  heading  will  be  therefore 
included  only  the  t>pes  of  hypersecretion  that  are  clinically  associated 
with  the  course  of  gastric  ulcer,  embracing  the  acute,  chronic,  and 
alimentary  forms. 

Acute  Hypersecretion  and  Ulcer. — Acute  hypersecretion  is  charac- 
terized by  attacks  in  which  the  gastric  juice  is  poured  out  in  large 
quantities  both  in  the  fasting  and  in  the  digesting  state. 


Fig.  25 


Vomitus  of  acute  hypersecretion  of  ulcer.  This  represents  the  amount  of  fluid  aspirated  from  the 
stomach  after  abstinence  from  all  food  and  fluids  for  twenty-six  hours.  Total  acidity,  68;  free  hydro- 
chloric acid,  52.     A  finely  chymified  food  residiie  is  seen  as  a  sediment. 

It  may  occur  as  an  early  symptom  of  ulcer,  or  may  apjx'ar  at  any 
time  during  the  course  of  the  disease,  e\cn  while  the  i)atieiit  is  under- 
going a  rigid  ulcer  cure.  Its  cause  is  regularly  a  sudden  jjyloric  obstruc- 
tion, most  commonly  from  a  muscular  spasm  of  th(>  ])ylori('  ring,  and 
almost  regularly  implies  an  ulcer  at  or  near  that  orifice.  It  is  one  of 
our  most  relialde  means  of  localization. 

There  is  the  complaint  of  more  or  less  e])igastric  ])ain  and  heart- 
burn, or  else  a  sense  of  gastric  fulness  and  nausea.  These  subjective 
symptoms  are  relieved  t(^  a  very  slight  degree  only,  and  but  for  a  short 


CHRONIC   ULCER  OF  THE  STOMACH 


12; 


time,  by  eating  or  by  alkaline  drinks.  Eating  may  aggravate  the 
discomfort.  Complete  relief  come.s  only  after  thorough  vomiting.  The 
act  of  vomiting  is  not  usually  accompan'ed  by  much  muscular  effort, 
but  the  fluid  easily  gushes  out,  often  in  large  quantities.  The  vomited 
fluid  is  either  colorless,  slightly  green  in  tinge,  or  else  brownish  from 
the  admixture  of  altered  blood.  There  are  no  visible  remains  of  ingested 
food  unless  food  has  recently  been  taken.  The  acidity  is  almost  invari- 
ably high,  ranging  usually  between  90  and  120,  the  greater  part  of  the 
acidity  being  due  to  free  hydrochloric  acid. 


Fig.  26 


XSODA 

Pain  curve  in  acute  hypersecretion  of  ulcer, 


<  VOMITING  OF  LARGE 
QUANTITY  OF  ACID  FLUID 


There  is  relief  after  the  vomiting  for  a  time,  usually  for  one  to  three 
hours,  but  distress  occurs  after  this  time,  merging  into  pain  with  a 
renewal  of  the  vomiting.  There  is  thus  a  certain  periodicity  in  the 
symptoms — usually  the  early  night  hours  are  the  ones  in  which  the 
pain  is  more  apt  to  oc(?ur. 

Such  an  attack  of  hypersecretion  may  last  a  few  days  or  it  may  be 
continued  throughout  the  disease.  Occurring  in  short  attacks  it  is 
often  mistaken  for  acute  gastritis,  but  the  fact  that  the  vomitus  is  of 
acid  fluid  and  not  of  food,  and  that  it  occurs  whether  the  patient  eats 
or  not,  should  definitely  exclude  acute  gastric  catarrh.  Occurring 
during  the  course  of  ulcer  it  is  usually  amenable  to  medical  treatment, 
although  in  severe,  untractable  cases  operative  interference  is  often 
necessary.  Operation  during  the  attack  is,  however,  to  be  deplored, 
owing  to  the  desiccation  of  the  patient's  tissues  by  the  withdrawal  of 
so  much  liquid  from  the  system.  The  history  of  such  a  patient  is  as 
follows : 

Mrs.  H.,  aged  thirty-five  years,  was  well  until  one  year  ago,  when 
she  suffered  from  gnawing  pain  in  the  stomach,  relieved  temporarily 
by  eating  or  by  vomiting,  the  vomited  matters  consisting  of  "acid 
scalding  water,"  that  she  would  vomit  "by  gushes."  This  acid  fluid 
vomiting  would  continue  the  same  whether  she  ate  or  not.  After  a 
month  the  symptoms  subsided  and  she  was  comparatively  well,  although 
she  complained  of  moderate  distress  two  hours  after  meals,  and  occa- 
sional heart-burn.     Two  months  ago  she  suffered  in  like  manner  from 


126  ACUTE  AND  CHRONIC  ULCER 

pain  and  acid-fluid  vomiting,  which  continued  in  spite  of  almost  com- 
plete abstinence  from  food  for  fourteen  days,  and  then  subsided,  only 
to  reappear  five  days  ago. 

Physical  examination  shows  well-marked  epigastric  and  dorsal 
points.  Splashings  are  readily  elicited  to  the  umbilicus,  although  no 
food  or  liquid  had  been  taken  for  twenty-four  hours.  There  is  moderate 
acetonemia. 

The  vomited  matters  are  watery,  slightly  greenish,  and  do  not 
contain  any  food  remains. 

Total  acidity,  104;  free  hydrochloric  acid,  84.  Lactic  acid,  negative. 
No  blood,  sarcinse,  or  bacilli.  Estimated  quantity  for  past  five  days  is 
between  two  and  three  pints  as  a  daily  average.  Liquid  nourishment 
has  not  exceeded  10  ounces  on  any  day.  Lnder  Lenhartz'  diet  and 
large  doses  of  bismuth  subcarbonate,  she  improved  steadily  and 
remained  comparatively  free  from  distress  for  three  months,  at  which 
time  she  had  a  large  hemorrhage  and  a  recurrence  of  her  acid  \'omiting. 
Operation  was  proposed  and  rejected,  and  the  patient  passed  from 
observation.  One  year  later  it  was  learned  that  she  was  in  a  sanatorium 
with  the  same  complaint. 

Chronic  Hypersecretion  in  Ulcer. — Chronic  hypersecretion  consists 
in  the  finding  of  gastric  juice  both  in  the  fasting  stomach  and  in  the 
digesting  stomach.  It  dift'ers  from  the  acute  form  not  only  in  its 
chronicity,  but  in  the  fact  that  it  never  reaches  the  excessive  degree 
commonly  seen  in  the  acute  cases.  The  theories  for  its  pathogenesis 
are  elsewhere  given,  but  the  author  believes  firmly  that  continuous 
secretion  means  only  one  thing — mild  pyloric  stenosis. 

In  ')()  per  cent,  of  the  writer's  cases  of  ulcer  the  stomach  contained 
in  the  fasting  state,  .'iO  to  (K)  c.c.  of  pure  gastric  juice  without  the  admix- 
ture of  food  remains.  The  symptom  to  which  it  gives  rise  is  hyper- 
acidity or  heart-burn  at  any  time  of  the  day  or  night  excepting  directly 
after  meals.  These  patients  are  never  without  their  soda  mints,  and 
they  keep  taking  them  long  after  the  hour  at  which  the  stomach 
should  normally  be  emi)ty.  These  cases  are  often  diagnosticated  as- 
sufl'ering  from  "hyperacidity"  or  "acid  catarrh  of  the  stomach." 

Chronic  hypersecretion  is,  however,  only  a  presumptive  proof,  at 
best,  of  ulcer.  Its  chief  significance  is  that  it  afl'ords  the  best  means 
available  of  localization,  imj)lying  regularly  a  lesion  at  or  near  the 
pylorus,  with  some  degree  of  narrowing  of  that  orifice. 

Alimentary  Hypersecretion  with  Ulcer. —  In  alimentary  hyjjersecretion 
there  is  ;iii  cxccssiN c  <|naiitity  of  gastric  juice  secreted  during  the 
digestive  period.  Tiie  fasting  stomach  is  practically  empty.  It  is 
present  in  many  chronic  conditions  of  the  .stomach  in  a  mild  degree, 
the  upper  hiyer  of  surplus  gastric  juice  in  the  test  breakfast,  after 


HEMORRHAGE  IN   ULCER  127 

staiifUng,  never  exceeding  in  depth  tliat  of  the  underlying  layer  of 
digested  breadstufl's. 

In  ulcer  we  have  a  distinct  group  in  which  the  amount  of  the  super- 
natant layer  of  surplus  gastric  juice  is  much  greater  than  this.  The 
fasting  stomach  is  empty,  so  that  pyloric  stenosis  is  definitely  excluded. 

The  test  breakfast  separates  on  standing  into  two  layers.  The 
upper  layer  of  surplus  gastric  juice  is  from  four  to  twenty  times  the 
depth  of  the  lower  layer  of  digested  breadstuff's.  The  acidity  is  almost 
invariably  high,  total  acidities  of  90  to  110  not  being  uncommon. 

Such  a  condition  may  give  rise  to  symptoms  which  may  be  readily 
inferred — pain  or  heart-burn  two  or  three  hours  after  meals,  at  the 
height  of  the  hypersecretion,  relieved  by  eating  or  by  vomiting,  or 
by  taking  soda. 

In  other  cases  distress  after  meals,  or  the  feeling  as  if  the  patient  had 
gas  on  his  stomach,  when  in  fact  none  is  there,  are  the  chief  symptoms. 
It  differs  from  the  course  of  ulcer  with  chronic  hypersecretion  in  that 
there  is  no  distress  at  the  time  when  the  stomach  should  be  normally 
empty. 

In  a  large  number  of  these  cases  a  von  Leube  ulcer  cure  will  relieve 
the  patient  from  all  discomfort,  and  from  his  clinical  history  we  would 
infer  that  he  was  again  possessed  of  a  normal  digestion.  The  examina- 
tion of  the  gastric  contents  will  almost  invariably  show  the  same 
amount  of  alimentary  hypersecretion  and  of  high  acidity,  the  only 
difference  being  that  the  patient  feels  well.  This  freedom  from  sub- 
jective discomfort,  with  the  continuance  of  unchanged  conditions  of 
gastric  secretions,  would  seem  to  indicate  that  the  ulcer  had  either 
healed  or  had  become  insensitive  to  acid  stimulation.  And  so  these 
patients  continue  for  years.  In  some  instances  the  subjective  sensa- 
tions return,  while  in  others  the  patients  feel  well  and  able  to  digest 
anything  without  discomfort,  but  still  show  their  alimentary  hyper- 
secretion and  their  high  acidity.  The  true  nature  of  the  complication 
is  not  known  at  the  present  time. 


HEMORRHAGE   IN   ULCER 

It  is  probable  that  the  great  majority  of  ulcers  give  rise  to  some 
degree  of  bleeding  at  some  time  during  their  clinical  course.  Hemor- 
rhage is,  however,  only  detected  when  visible  blood  is  present  in  vomited 
matters  or  in  the  stools,  or  whenever  clinical  tests  of  gastric  or  intestinal 
contents  reveal  the  presence  of  blood,  which  by  processes  of  exclusion 
can  be  inferred  to  originate  from  the  stomach.  We  distinguish,  there- 
fore, visible  hemorrhages  and  occult  hemorrhages. 


128 


ACUTE  AND  CHRONIC   ULCER 


Types. — Visible  Hemorrhages. — Visible  hemorrhages  in  the  form  of 
hematemesis  or  meleiia  occur  in  a  large  number  of  cases  of  ulcer  of 
the  stomach,  variously  estimated  by  difi'erent  observers.  SO  per  cent, 
of  Lebert's  cases  were  marked  by  hemorrhage,  71  per  cent,  of  Fen- 
wick's,  50  per  cent,  of  Ewald's.  Hemorrhage  complicated  SO  per  cent, 
of  ulcer  cases  at  the  University  College  Hos])ital,  and  00  per  cent,  of 
similar  cases  at  the  Royal  Victoria  Hospital.  ^Stockton,  on  the  other 
hand,  finds  hemorrhage  in  only  25  per  cent,  of  cases,  and  his  compiled 
statistics  show  that  only  2S  per  cent,  of  ulcers  give  rise  to  visible  hemor- 
rhages. Statistics  on  this  point  are  apt  to  be  very  misleading.  In 
hospitals  the  severer  forms  of  ulcer,  especially  those  with  hemorrhage, 
are  relatiAely  more  frequent  than  ulcers  which  do  not  give  rise  to 
such  alarming  symptoms. 

Fig.   27 


Duodenal  ulcer  showing  erosion  of  an  artery  in  the  base,  from  wliieh  fatal  hemorrhage  occurred. 


In  the  writer's  cases  49  per  cent,  of  tliose  in  hospital  i)ractice  gave 
the  iiistory  of  vomiting  of  blood,  while  in  his  })rivate  i)ractice  only 
25  per  cent,  gave  this  history.  It  is  not  because  the  type  of  ulcer  is 
different,  !)Ut  because  those  ulcers  which  do  not  bleed  are  aj^t  to  be 
treated  in  disju'iisaries,  while  i)atients  with  hemorrhages  are  alarmed, 
and  naturally  enter  the  h()S])ital  wards.  rnd()iil)tedly  many  cases  of 
lu-morrhage  from  es()|)hag<'al  \arices  are  iiHliidecj  among  the  ulcer 
cases. 

The  souree  of  llie  lieiiiorrliage  is  usually  from  an  eroded  artery — 
less  frer|iieiilly  of  xciioiis  origin. 

Savariaud  in  54  cases  found  a  venous  origin  in  4  eases,  the  sj)leiiic 
artery  in   17,  coronary  artery  in  (i,  gastric  artery  in   10,  pancreatico- 


HEMORRHAGE  IN   ULCER  129 

duodenalis  in  7,  while  in  10  the  source  of  the  hemorrhage  was  undeter- 
mined. The  bleeding  may  come  from  the  rupture  of  a  small  artery 
at  the  base  of  the  ulcer,  from  erosion  of  the  spleen  itself,  or  even  from 
the  aorta. 

The  hemorrhage  may  occur  at  any  time,  but  especially  after  meals 
during  the  digestive  congestion  of  the  stomach,  and  at  a  time  when 
the  walls  of  the  stomach  are  put  on  a  stretch. 

In  some  cases  the  hemorrhage  is  preceded  by  an  increase  of  the 
ulcer  pain,  from  which  we  may  infer  that  an  extension  of  the  ulcerative 
process  has  taken  place. 

If  the  hemorrhage  be  large  and  sudden,  the  patient  will  suddenly 
become  faint  and  dizz3^  There  may  be  pain,  often  quite  severe,  pre- 
ceding the  onset  of  the  bleeding,  and  relieved  by  the  flow  of  blood. 
Sudden  anemic  .symptoms  develop  according  to  the  amount,  to  a  less 
extent  upon  the  rapidity  of  the  hemorrhage — pallor,  faintness,  even 
complete  syncope,  collapse  with  dyspnea,  amounting  to  air  hunger 
in  the  severer  cases,  rapid  pulse  of  low  arterial  tension. 

The  shock  may  be  so  great  as  to  inhibit  attempts  at  vomiting,  but 
in  the  majority  of  cases  blood  is  vomited,  more  or  less  clotted,  and 
more  or  less  altered  in  color,  according  to  the  length  of  time  it  has 
been  retained  in  the  stomach.  Admixture  of  blood  with  food,  and  blood 
of  a  brownish  tinge  from  the  action  of  the  gastric  juice,  are  indications 
of  its  gastric  origin,  although  it  must  be  remembered  that  blood  from 
rupture  of  esophageal  varices  or  even  of  pulmonary  origin  may  pass 
into  the  stomach  and  thence  be  vomited. 

The  reaction  from  gastric  hemorrhage  is  usually  accompanied  by 
moderate  fever. 

Within  a  few  hours  or  days,  blood  appears  in  the  stools.  The  typical 
stool  under  these  circumstances  is  of  a  tarry  appearance  and  quite 
offensive.  It  may  be  difficult  to  determine  by  gross  examination 
whether  the  blackish  color  is  due  to  medicine  recently  administered, 
such  as  bismuth  or  iron,  or  is  due  to  altered  blood,  but  upon  shaking 
the  stool  with  a  little  water  there  is  usually  a  crimson  or  magenta 
discoloration  of  the  water  which  is  quite  distinctive.  Chemical  tests 
for  food  of  course  give  final  and  definite  information.  If  the  hemor- 
rhage be  large,  and  rapidly  passed  through  the  intestines,  the  color  of 
the  blood  is  brighter,  although  it  may  be  said,  as  a  general  rule,  that 
blood  passed  per  rectum,  that  is  by  its  color  and  appearance  recognized 
as  blood,  rarely  comes  from  a  source  as  high  as  the  stomach.  In  the 
cases  of  melena  without  hematemesis,  the  source  of  the  bleeding  is 
usually  from  a  duodenal  ulcer. 

If  the  hemorrhage  be  less  marked,  and  not  accompanied  by  vomiting, 
there  may  be  only  an  attack  of  faintness  and  a  sudden  pallor.  If  the 
9 


130  ACUTE  AND  CHRONIC   ULCER 

hemorrhages  are  repeated,  even  if  moderate  in  amount,  the  only 
symptom  may  be  an  increasing  anemia.  This  may  be  so  extreme  as 
to  simulate  pernicious  anemia  or  malignant  cachexia.  The  rule 
should  be  to  examine  stools  for  blood  in  every  case  of  sudden  or 
obscure  anemia. 

In  Acute  Ulcer. — Hemorrhage  in  acute  ulcer  often  occurs  as  an 
initial  symptom  preceding  the  advent  of  pain.  This  occurred  in  75.4 
per  cent,  of  Fenwick's  cases.  This  seems  to  the  writer  to  be  altogether 
too  high  a  figure,  as  in  his  experience  hemorrhage  occurred  as  the  first 
symptom  in  but  20  per  cent,  of  the  acute  cases. 

The  hematemesis  of  acute  ulcer  is  regularly  more  sudden  and  pro- 
fuse than  in  the  chronic  forms  of  ulceration  for  the  reason  that  the 
walls  of  the  ulcer  are  soft  and  the  vessel  wall  normal,  whereas  in  the 
chronic  form  the  walls  of  the  nutrient  vessels  are  often  thickened  and 
its  lumen  diminished. 

Fatality. — The  fatality  of  hemorrhage  varies  according  to  different 
observers. 

Rodman  claims  that  40  per  cent,  of  cases  with  gastric  hemorrhage 
die;  Mayo  Robson  estimates  the  fatality  at  04  })er  cent.  Fatal  hemor- 
rhage, on  the  other  hand,  occurred  in  but  5  per  cent,  of  Brinton's 
cases,  and  3.4  per  cent,  of  Fenwick's.  Robson  claims  that  hemorrhage 
causes  the  death  of  7  per  cent,  of  ulcer  cases,  basing  this  figure  from  a 
compilation  of  statistics. 

The  writer's  experience  is  as  follows:  In  cases  taken  from  both 
hospital  and  private  practice,  hemorrhage,  mild  and  severe,  occurred 
in  37.6  per  cent. — fatal  hemorrhage  in  3.1  per  cent.  The  proportion 
of  non-fatal  to  fatal  hemorrhage  is,  therefore,  as  10  to  1. 

It  is  interesting  to  note  that  while  the  proportion  of  hemorrhages  is 
much  greater  in  the  hospital  series,  the  proportion  of  hemorrhages  that 
are  recovered  from  to  those  that  are  fatal  is  the  same  in  both  series. 


Private  cases 82 

No  hemorrhages  in 

Hemorrhages  in 

Fatal  in 

Proportion  of  non-fafal  to  fatal,  10  to  1. 
Hospital  cases 77 

No  hemorrhages  in 

Hemorrhages  in 

Fatal  in 

Proportion  of  non-fatal  to  fatal,  12  to  1. 
Total  cases 159 

No  hemorrhages  in 

Hemorrhages  in 

Fatal  in 

Proportion  of  non-fatal  to  fatal,  10  to  1. 


Cases.      Per  cent. 


60 

75.0 

22 

25.0 

2 

2.5 

39 

51.0 

38 

49.0 

3 

4.0 

65.5 

34.5 

3.1 

HEMORRHAGE  IN   ULCER  131 

Melena  in  infants  occurs  once  in  about  1000  live  births,  but  in  only 
a  very  small  number  of  cases  can  it  be  traced  to  ulcer.  The  number  of 
infants,  however,  who  die  from  duodenal  ulcer  is  greater  than  is  ordi- 
narily supposed.  The  hemorrhage  may  appear  shortly  after  birth,  and 
be  quickly  followed  by  death  in  collapse.  Vomiting  of  blood  is  rare: 
melena  being  usually  the  only  manifestation  of  the  bleeding. 

Helmholz,^  in  a  recent  interesting  article,  has  brought  to  our  atten- 
tion the  frequent  association  of  duodenal  ulcer  and  marasmus.  Of 
16  cases  of  infantile  atrophy  coming  to  autopsy,  duodenal  ulcer  was 
present  in  8.  The  ulcers  may  be  single  or  multiple,  their  edges  are 
usually  more  sharp  and  abrupt  than  those  found  in  adults.  In  none 
of  the  cases  was  there  any  evidence  of  repair.  In  these  marasmic 
cases  a  long  period  of  weakness,  wasting,  and  anemia  preceded  the 
occurrence  of  hemorrhage.  Helmholz  believes  that  the  long  and 
wasting  disease  so  enfeebles  and  devitalizes  the  infant  that  it  falls  an 
easy  victim  to  the  disease. 

To  the  history  of  these  8  fatal  cases  Helmholz  adds  that  of  the  ninth 
case  of  marasmus  and  melena — in  all  probability  due  to  duodenal  ulcer, 
which  eventuated  in  recovery. 

It  is  often  difficult  to  decide  whether  hemorrhages  are  really  of 
gastric  origin.  Blood  may  come  from  lung,  nose,  or  throat,  and  be 
swallowed  and  subsequently  vomited,  with  all  the  characteristics  of 
hematemesis  of  gastric  origin.  In  these  cases,  however,  the  presence 
of  blood-stained  sputum  or  the  examination  of  nose  and  nasopharynx 
usually  reveals  the  initial  set  of  hemorrhage 

Blood  of  esophageal  origin  may  be  more  difficult  of  detection. 

Most  common  are  the  esophageal  varices  consequent  on  the  venous 
stasis  of  cirrhosis  of  the  liver.  In  these  cases  the  previous  history  is 
rather  that  of  alcoholic  gastritis  than  of  ulcer.  Hyperacidity  symptoms 
are  but  rarely  observed,  as  subacidity  or  even  achylia  is  the  rule, 
while  the  physical  symptoms  are  those  of  hepatic  cirrhosis.  It  must 
be  remembered,  however,  that  cirrhosis  often  occurs  without  changes 
in  the  size  of  the  liver,  and  that  enlargements  of  the  spleen  may  disap- 
pear after  the  reduction  of  the  portal  congestion  by  free  bleeding.  As 
a  rule,  hemorrhage  from  esophageal  varix  appears  suddenly  and  pro- 
fusely, but  is  not  apt  to  be  repeated  in  that  patient.  Repeated  hemor- 
rhages suggest  gastric  ulcer. 

Esophageal  bleeding  may  occur  from  the  gradual  leakage  or  sudden 
perforation  of  a  thoracic  aneurysm.  The  previous  history  should 
clear  the  diagnosis  beyond  point  of  doubt.  Patients,  however,  who 
enter  the  hospital  with  such  an  accident  usually  die  before  a  full  clinical 
history  can  be  obtained. 

1  Deutsch.  med.  Woch.,  1909,  i,  534. 


132  ACUTE  AND  CHRONIC   ULCER 

Hemorrhage  from  the  stomach  occurring  in  cancer  is  described  in 
the  chai)ter  on  that  disease. 

Severe  hemorrhages,  often  so  profuse  as  to  be  fatal,  may  occur  from 
pore-like  erosions  of  the  mucosa,  often  so  minute  as  almost  to  baffle 
detection.  These  cases,  described  by  Dieulafoy  under  the  name  of 
exulceratio  simplex,  are  described  under  a  separate  heading  (p.  105). 
Under  the  same  heading  are  also  included  the  general  oozing  of  blood 
from  the  gastric  mucous  membrane  to  which  attention  has  been  called 
by  Hale  ^Vhite,^  and  designated  by  him  gastrostaxis.  In  the  same 
category  are  placed  the  various  post  hemorrhages  of  gastric  origin  that 
follow  abdominal  operations,  and  the  hematemesis  that  not  infre- 
quently complicates  the  course  of  chronic  appendicitis.  For  a  con- 
sideration of  the  above  cases,  the  reader  is  referred  to  the  section  on 
Hemorrhagic  Erosions  (p.  192). 

Hemorrhages  from  the  stomach,  not  due  to  ulcer,  cancer,  or  pore-like 
erosions,  may  occur  from  rupture  of  venous  varices  in  the  stomach 
itself,  from  rupture  of  aneurysm  of  any  of  the  neighboring  arteries 
into  its  lumen,  or  from  hemorrhagic  blood  diseases,  such  as  hemaphilia, 
the  various  forms  of  purpura,  splenic  anemia,  leukemia,  and  intense 
infections  accompanied  by  extreme  hemolysis. 

Occult  Hemorrhages. — Occult  hemorrhages  are  much  more  frequent 
than  those  that  are  evident  and  visible,  and  their  detection  constitutes 
one  of  the  greatest  advances  made  in  gastric  clinical  work. 

It  is  a  well-known  fact  that  blood  may  be  present  in  the  bowel 
movements  and  yet  be  undetected,  as  owing  to  alterations  in  its  color, 
and  to  the  small  amount  present,  no  evident  changes  are  observed 
in  the  color  or  appearance  of  the  stools,  and  it  is  onlj'  by  delicate 
chemical  tests  that  its  presence  becomes  known. 

The  examination  for  occult  hemorrhages  in  gastric  ulcer  must,  of 
course,  be  preceded  by  an  exclusion  of  all  other  sources  for  blood,  such 
as  bleeding  gums,  epistaxis,  traumatism,  such  as  the  passage  of  a 
stomach-tube,  intestinal  ulcers,  hemorrhoids,  and  rectal  fissures. 
vSystemic  diseases  such  as  purpura,  typhoid  fever,  arteriosclerosis, 
and  tabes  with  gastric  crises  must  also  be  considered.  The  ingestion 
of  raw  or  uncooked  meat,  beef  juice,  or  sausage  will  give  i)ositive 
reactions. 

Thoroughly  cooked  meats  do  not  interfere  with  the  test,  but  in 
doubtful  cases  in  which  much  depends  upon  the  result  of  the  exami- 
nation it  is  best  to  run  no  chances  and  to  exclude  all  meats  from  the 
diet  for  two  days  preceding  the  examination.  This  naturally  need 
not  be  done  unless  positive  blood  reactions  are  ]>resent  on  a  mixed 
diet. 

'  Lance),  lOOO,  Xo.  3. 


HEMORRHAGE  IN   ULCER  133 

For  the  examination  to  be  of  any  clinical  significance  the  following 
precautions  should  be  taken. 

1.  No  stool  should  be  examined  which  shows  any  trace  of  blood  on 
its  surface. 

2.  Always  test  from  the  centre  of  the  stool  cylinder. 

3.  If  the  patient  be  at  all  constipated,  give  a  mild  laxative,  just 
sufficient  to  soften  the  movement,  so  that  it  does  not  abrade  the  lower 
portion  of  the  bowels  and  cause  bleeding. 

Tests. — The  tests  ordinarily  employed  are  benzidin,  the  aloin,  and 
the  guaiac  tests.  The  spectroscopic  test  and  the  microchemical  test 
of  Teichmann  are  not  as  frequently  used  as  formerly  and  need  not, 
therefore,  be  described. 

Benzidin  Test. — Knife  point  of  pure  benzidin  (Merck)  is  dissolved 
by  gentle  shaking  in  2  or  3  cm.  of  glacial  acetic  acid.  A  small  piece 
of  well-mixed  feces  is  then  ground  with  distilled  water  to  the  con- 
sistency of  a  thin  paste,  placed  in  a  test-tube,  and  boiled  for  about  a 
minute.  The  contents  are  then  diluted  with  an  equal  quantity  of 
water  and  cooled.  1  c.c.  of  the  benzidin  solution  is  poured  in  a  clean 
test-tube,  3  to  10  drops  of  the  feces  solution  added,  and  after  they 
have  been  well  shaken,  1  to  3  c.c.  of  a  3  per  cent,  solution  of  hydrogen 
peroxide  are  added,  and  the  whole  well  shaken. 

In  the  presence  of  blood,  a  green,  blue-green,  or  dark  blue  color 
appears,  the  blue  being  more  marked  the  larger  the  amount  of  blood 
present.  Large  quantities  of  blood  show  an  almost  instantaneous 
reaction — the  very  small  quantities  give  a  decided  reaction  within 
two  minutes.  A  negative  test  gives  no  blue  or  green  color,  which 
alone  is  characteristic,  even  on  standing  twenty-four  hours. 

The  quantities  of  the  reagents  must  be  carefully  observed  and  the 
test-tubes  and  apparatus  absolutely  clean.  Test-tubes  in  which 
Fehling's  solution  has  been  boiled  should  not  be  used. 

The  following  substances  besides  blood  which  give  the  reaction  are 
oxidizing  ferments  (these  are  destroyed  by  boiling),  potassium  iodide, 
animal  charcoal,  iron  and  copper  salts.  Potato  and  farina  are  said  to 
give  a  slightl}^  positive  test.  Pus,  saliva,  and  nasal  secretions  may 
give  a  more  or  less  marked  reaction. 

The  benzidin  test  gives  a  reaction  of  1  to  200,000  of  blood.  The 
only  objection  to  this  test  is  that  it  is  somewhat  overdelicate  for 
ordinary  clinical  work. 

Aloin  Test. — About  5  grams  of  the  feces  are  ground  up  with  distilled 
water  until  they  are  of  a  semifluid  consistency,  and  poured  into  a  large 
test-tube.  The  fat  is  then  removed  by  shaking  with  an  equal  volume 
of  ether,  and  after  standing  the  ether  is  poured  off.  The  residue  is 
then  mixed  with  one-third  of  its  volume  of  glacial  acetic  acid  and  well 


134  ACUTE  AND  CHRONIC   ULCER 

shaken.  The  aloin  sokition  is  prepared  by  dissolving  a  knife  point  of 
Barbadoes  aloes  in  5  c.c.  of  70  per  cent,  alcohol.  This  must  always 
be  freshly  made.  The  acetic  acid-ether  extract  is  then  poured  off  the 
feces  and  2  or  '3  cm.  of  old  ozonated  turpentine  is  added.  In  the  presence 
of  blood  a  pink,  deepening  to  cherry-red  color  appears,  usually  within 
a  few  seconds,  although  in  less  marked  cases  the  color  reaction  may 
not  api)ear  in  less  than  five  to  ten  minutes.  If  a  reaction  does  not 
occur  within  fifteen  minutes,  it  should  be  declared  negative.  The 
aloin  test  gives  a  reaction  of  1  to  25,000  of  blood,  which  is  sufficiently 
delicate  for  ordinary  clinical  work. 

Guaiac  Test. — The  guaiac  test  is  performed  as  the  aloin  test  except 
that  a  fresh  solution  of  guaiac  in  alcohol  is  employed  instead  of  the 
aloin.  In  the  presence  of  l)lood  a  blue  color  appears,  although  in  weak 
reactions  the  blue  may  be  masked  b}'  the  stercobilin  of  the  feces,  and 
is  then  seen  as  an  olive  green  or  a  greenish  purple. 

The  guaiac  test  is  of  the  same  sensitiveness  as  the  aloin  test. 

Benzidin  Paper  Test. — Benzidin  paper  is  made  by  moistening  filter 
paper  with  a  saturated  solution  of  benzidin  in  glacial  acetic  acid. 
During  the  process  contact  with  the  fingers  must  be  avoided,  as  per- 
spiration gives  a  positive  reaction.  A  piece  of  the  dried  benzidin 
paper  is  immersed  in  the  fecal  solution  to  be  examined,  and  then  a 
few  drops  of  a  3  i)er  cent,  solution  of  hydrogen  peroxide  are  added. 
A  positive  reaction  should  appear  within  one  minute^otherwise  the 
test  should  be  considered  negative.  In  doubtful  reaction  controls 
by  one  of  the  other  tests  should  be  employed. 

Results  of  the  tests  for  occult  bleeding  in  ulcer  are  to  be  regarded 
as  negative  only  after  three  or  four  tests  at  least  are  taken,  as  experi- 
ence has  shown  that  positive  reactions  occur  more  intermittently  in 
ulcer  than  in  cancer.  The  tests  are  valuable  not  only  as  an  aid  to 
diagnosis,  but  as  an  indication  as  to  whether  during  treatment  the 
ulcer  is  healing  or  is  still  open.  Rutimeyer  found  a  positive  reaction 
in  42  per  cent,  of  his  ulcer  cases. 

During  the  course  of  an  ulcer  treatment  the  stools  should  be  repeatedly 
examined  for  occult  })leeding,  especially  after  a  return  to  solid  diet. 
If  the  hemorrhage  returns  on  a  solid  diet,  it  should  disa])pear  again 
on  resumption  of  liquid  food.  Suspicion  of  malignancy  should  be 
entertained  toward  those  cases  of  presumed  ulcers  which  bleed  when 
solid  food  is  resumed  after  an  ulcer  cure.  //  an  ulcer  case  of  adiiJt  years 
dors  not  iiti prove  on  an  ulcer  treatment,  hat  while  on  meat-free  diet  shows 
occult  hciuorrluKjcs,  the  case  should  he  looked  upon  with  susin'cioji,  and. 
should  hriiKj  uj)  for  considcrafiou  the  (/urstion  of  e.vjdoration.  In  this 
way  many  cases  of  carcinoniii  will  be  discoxcrcd  in  their  operative 
period. 


GASTRIC  ANALYSIS  135 


GASTRIC    ANALYSIS 


The  passage  of  a  tube  during  acute  ulceration  of  the  stomach  is 
a  hazardous  procedure  and  absokitely  unjustifiable  on  any  grounds 
whatever.  Unfortunately  a  large  number  of  casualties  have  followed 
the  disregard  of  this  rule.  Equally  dangerous  is  it  to  pass  a  tube 
during  the  acute  exacerbations  of  chronic  ulcer  in  which  an  increase 
in  the  severity  and  constancy  of  the  pain  and  in  localized  epigastric 
tenderness  are  warning  signs  of  possible  perforation.  The  tube  should, 
moreover,  never  be  passed  in  cases  with  recent  hemorrhage. 

In  chronic  ulcer  the  passage  of  a  tube  is  not  especially  dangerous, 
and  the  writer  has  never  seen  any  unpleasant  results  follow  its  use. 
Upon  the  least  evidence  of  pain  or  hemorrhage  the  tube  should  at 
once  be  withdrawn. 

Gastric  analysis  may  or  may  not  be  of  service  in  diagnosis.  Valuable 
assistance  may  be  afforded  in  determining  the  presence  of  an  ulcer  and 
its  probable  location,  but  it  should  be  remembered  that  normal  gastric 
secretions  offer  in  themselves  no  reason  for  doubting  the  existence  of 
an  ulcer  whose  presence  is  suggested  by  the  clinical  history. 

Hyperacidity. — There  has  been  a  great  deal  written  on  the  relation 
of  hyperacidity  to  ulcer,  the  consensus  of  opinion  being  that  hyper- 
acidity is  the  rule.  It  has  been  argued  that  hyperacid  conditions, 
howsoever  induced,  precede  the  formation  of  ulcer,  and  that  the  hyper- 
peptic  gastric  juice  with  its  increased  eroding  quality  is  an  important 
factor  in  its  genesis.  This  is  doubtful.  In  atonic  conditions  and  in 
gastroptosis,  in  which  hyperacidity  is  so  frequent  and  in  other  cases 
of  functional  hyperacidity  there  seems  to  be  no  more  liability  to  ulcer 
than  when  the  gastric  juice  is  normally  acid,  neither  is  it  necessary  to 
have  a  hyperpeptic  secretion  for  the  erosion  of  a  part  of  the  gastric 
mucosa  because,  if  an  area  of  diminished  local  vitality  is  present, 
gastric  juice  of  normal  strength  will  do  its  eroding  work  quite  as  well. 

There  is  no  doubt  that  the  majority  of  chronic  ulcers  are  accom- 
panied at  some  period  or  another  in  their  course,  by  increased  acidity 
of  the  gastric  secretions,  but  this  hyperacidity  is  not  constant,  nor  is  it 
ordinarily  observed  in  the  acute  forms  of  ulcer,  while  not  infrequently 
ulceration  takes  place  when  the  acidity  of  the  gastric  juice  is  greatly 
diminished. 

Eisner,  Strauss,  and  Riitimeyer,  writing  independently  of  each 
other,  have  called  attention  to  the  differences  in  this  regard  in  ulcers 
from  various  geographical  regions,  higher  acidities  being  more  common 
in  England  and  the  United  States,  apparently,  than  in  Germany. 

The  proportion  of  ulcers  accompanied  by  hyperacidity  is  not  an 


13G 


ACUTE  AND  CHRONIC   ULCER 


overwhelming  one,  the  estimates  varying  from  35  to  75  per  cent.    The 
principal  statistics  are  shown  in  the  following  table: 

Ewald  found  hyperacidity  in 34  per  cent. 

Moynihan'  found  hyperacidity  in 40  per  cent. 

Wagner  found  hyperacidity  in 42  per  cent. 

Wirsung  found  hyperacidity  in 42  per  cent. 

Riitimeyer  found  hyperacidity  in 42  per  cent. 

Oeruni  found  hyperacidity  in 56  per  cent. 

Fenwick  found  hyperacidity  in  .    _ .  .      .66  per  cent. 

In  the  writer's  series,  hyperacidity  of  70  or  over  was  found  in  32  per 
cent,  of  the  acute  ulcers,  and  in  50  per  cent,  of  the  chronic  cases.  The 
author's  statistics  are  as  follows: 

Acidity  of  Test  Breakfast  in  Acute  ulcer 


Total  acidity 

.     40  to    50 

17  per  cent. 

Total  acidity 

.     50  to    60 

34  per  cent. 

68  per 

cent. 

Total  acidity 

.     60  to    70 

17  per  cent.  . 

Total  acidity 

.     70  to    80 

16  per  cent.  ^ 

Total  acidity 

.     80  to    90 

9  per  cent. 

32  per 

cent. 

Total  acidity 

.     90  to  100 

7  per  cent.  ; 

100  per  cent. 

100  per 

cent. 

Acidity  of  Te 

ST  Breakfast 

IN  Chronic  Ulcer 

Total  acidit}^    . 

30  to    40 

10  per  cent.  > 

Total  acidity   . 
Total  acidity    . 

40  to    50 
50  to    60 

14  i^er  cent. 
14  per  cent. 

50  per 

cent. 

Total  acidity 

60  to    70 

12  per  cent.   > 

Total  acidity 

70  to    80 

16  per  cent. 

Total  acidity 

80  to    90 

10  per  cent. 

Total  acidity    . 

90  to  100 

8  per  cent. 

50  per 

cent. 

Total  acidity 

100  to  110 

S  per  cent. 

Total  acidity 

110  to  120 

8  per  cent.  ^ 

100  per  cent.     100  per  cent. 

In  these  tables  arc  inchulcd  all  cases  of  ulcer  of  stomach  or  duodenum, 
irrespective  of  their  situation  as  regards  the  pylorus.  It  will  thus  be 
seen  that  in  acute  ulcer  the  acidity  is  not  as  high  as  in  the  chronic 
form,  and  acidities  over  100  did  not  occur. 

After  a  careful  analysis  of  his  cases,  the  writer  believes  that  hyper- 
acidity is  not  a  necessary  result  of  ulcer.  When  an  ulcer  is  situated  in 
a  location  which  does  not  involve  the  i)ylorus,  hyperacidity  is  rather 
rare,  but  whenever  an  ulcer  of  the  stomach  infringes  ui)on  the  ])ylorus 


'  Lancet,  January  6,  1912. 


GASTRIC  ANALYSIS  137 

SO  as  to  interfere  in  the  slightest  degree  with  its  patency,  or  whenever 
by  its  propinquity  it  causes  pyloric  spasm,  a  definite  hyperacidity 
results. 

Hyperacidity  in  ulcer  depends  upon  the  localization  of  the  ulcer 
rather  than  upon  the  ulcer  jjer  se. 

The  writer's  conclusions  are  based  upon  the  following  statistics: 

Ulcers  not  Involving  the  Pylorus 

Low  acidity 9  per  cent. 

Normal  acidity 75  per  cent. 

Hyperacidity •     ....  16  per  cent. 

Ulcers  at  or  Near  the  Pylorus 

Low  acidity 0  per  cent. 

Normal  acidity 18  per  cent. 

Hyperacidity 82  per  cent. 

The  author  believes  that  the  importance  of  the  location  of  the  ulcer 
influencing  hyperacidity  has  not  been  as  yet  fully  recognized.  It  is 
acting  upon  this  hypothesis  that  he  is  led  to  describe  the  results  of 
gastric  analysis  in  ulcer  under  two  separate  headings. 

1.  In  ulcers,  gastric  or  duodenal,  that  are  not  situated  near  the 
pylorus,  and  w^hich  therefore  do  not  directly  or  indirectly  impair  the 
patency  of  that  orifice,  gastric  analysis  is  of  very  little  service  what- 
ever. The  fasting  stomach  is  empty.  The  test  breakfast  presents  a 
normal  appearance,  and  is  usually  of  normal  acidity.  An  increase  in 
gastric  mucus  is  not  noted.  The  only  help  in  diagnosis  that  may  be 
afforded  is  the  presence  of  old  altered  blood  in  the  gastric  contents. 

2.  Of  more  importance  are  the  gastric  tests  made  w^ith  ulcers,  gastric 
or  duodenal,  that  directly  or  indirectly  affect  the  patency  of  the  pyloric 
orifice,  either  by  thickening  of  the  tissues  of  the  pyloric  ring,  cicatricial 
contraction,  vascular  tumefaction,  or  spasm.  Hyperacidity  is  the  rule. 
Hypersecretion  occurs  in  a  large  number  of  the  cases. 

The  fasting  stomach  may  be  empty,  or  may  contain  from  25  to  50 
c.c.  of  a  clear  fluid  of  normal  or  excessive  acidity  and  without  gross 
admixture  of  food  residue,  although  a  few  scanty  food  remains  may  be 
found  under  the  microscope.  This  mild  hypersecretion  occurred  in 
50  per  cent,  of  the  total  number  of  the  author's  chronic  ulcer  cases. 
Presence  of  residual  food  implies  more  advanced  pyloric  stenosis. 

This  slight  excess  of  gastric  secretion  in  the  fasting  stomach,  asso- 
ciated clinically  with  hunger  pain,  affords  a  strong  presumptive  proof 
of  ulcer  provided  we  can  exclude  chronic  inflammation  of  the  appendix. 

Test  breakfast  is  usually  well  digested  and  free  from  gastric  mucus. 
It  may  be  of  normal  appearance,  but  more  usually  it  separates  upon 


138  ACUTE  AND  CHRONIC   ULCER 

standing  into  two  layers,  one  of  fluid  above,  and  one  of  digested 
breadstuff  below.  A  certain  degree  of  alimentary  hypersecretion  is 
common  to  all  atonic  conditions  of  the  stomach,  but  in  atony  the 
depth  of  the  sui)ernatant  layer  should  never  exceed  that  of  the  lower. 
In  ulcer  the  amount  of  hypersecretion  may  be  more  than  this,  the 
depth  of  the  liquid  layer  being  occasionally  four  to  twenty  times  that 
of  the  underlying  stratum.  These  excessive  amounts  of  alimentary 
hypersecretion  are  not  common,  but  they  do  occur. 

The  acidity  of  the  filtrate  is  usually  above  the  normal,  total  acidities 
of  80  to  95  being  the  rule.  More  rarely  higher  figures  are  attained, 
100  to  120. 

Whenever  spasm  of  the  pylorus  or  tumefaction  of  the  orifice  occurs, 
the  acidity  of  the  test  breakfast  or  of  the  vomited  matters  becomes 
excessively  high,  occasional!}^  attaining  130  to  150,  and  the  increased 
acidity  is  often  complicated  by  an  increase  in  the  actual  quantity  of 
the  gastric  juice  that  is  poured  out.  As  conditions  improve,  hyper- 
secretion diminishes. 

The  following  case  may  be  quoted  as  an  example.  W.  E.  C.  C, 
aged  forty -five  years.  Five  years  ago  suffered  for  one  month  with 
constant  gnawing  pain  in  the  stomach  before  meals,  relieved  by  the 
taking  of  food.  Four  years  ago  this  pain  reappeared  and  has  remained 
ever  since  with  but  short  periods  of  intermission.  Two  years  ago  he 
had  a  large  intestinal  hemorrhage. 
Fasting  stomach  empty. 

Test  breakfast,  100  c.c,  well  digested,  separates  on  standing  into 
layers  of  ecjual  depth.  No  mucus.  Total  acidity,  48;  free  hydrochloric 
acid,  24.    Blood  test  negative. 

Was  placed  on  ulcer  cure.  On  the  third  day  of  his  starvation,  vomited 
14  ounces  of  a  clear  greenish  fluid  (total  acidity,  98),  followed  in  a  few 
hours  by  the  vomiting  of  2  pints  of  similar  fluid  of  the  total  acidity  of 
132.  Under  appropriate  treatment  the  vomiting  ceased,  and  for  the 
past  seven  years  there  has  been  no  recurrence.  Gastric  analysis  at 
the  end  of  a  month's  ulcer  cure  showed  total  acidity,  78;  free  hydro- 
chloric acid,  48. 

A  differential  diagnosis  between  gastric  and  duodenal  ulcer  cannot 
be  made  by  examination  of  either  the  fasting  or  the  digesting  stomach. 
Inasmuch  as  the  majority  of  duodenal  ulcers  are  situated  near  the 
l)yIorus,  tumefaction  or  spasm  is  apt  to  occur,  diminishing  the  lumen 
of  that  orifice  and  allowing  of  a  higher  acidity  than  is  found  in  gastric 
ulcer  taken  as  a  whole,  although  between  duodenal  ulcer  and  gastric 
ulcer  equally  near  the  pylorus  there  seems  to  be  no  difference  in  acidity. 
Neither  is  it  possil)le  to  dillerentiate  with  certainty  between  ulcer 
and  cancer  of  the  stomach  by  gastric  analysis  alone.     The  writer  has 


PHYSICAL  SIGNS  OF  ULCER  139 

found  in  cancer  that  15  per  cent,  of  the  test  breakfasts  show  nothing 
that  is  indicative  of  malignancy;  hydrochloric  acid  is  present;  lactic 
acid  is  negative;  bacilli  and  evidences  of  stagnation  are  not  present. 
In  the  remaining  85  per  cent.,  however,  more  positive  evidences  of 
malignancy  are  found. 

In  chronic  ulcer  it  is  important  to  follow  our  cases,  and  to  make 
gastric  analyses  from  time  to  time.  It  has  been  stated  that  whenever 
malignancy  develops  on  the  site  of  an  old  ulcer,  the  first  change  evi- 
dent is  a  gradual,  though  steady  reduction  in  the  acidity  of  the  gastric 
secretions. 

The  writer  cannot  give  his  personal  experience  on  this  point,  as  he 
has  seldom,  if  ever,  noticed  such  a  primary  lowering  of  acidity  in  these 
cases.  In  his  experience,  however,  the  first  evidence  of  beginning 
malignancy  has  been  traces  of  lactic  acid.  Lactic  acid,  even  in  small 
traces  in  the  stomach  contents  of  ulcer  patients,  should  always  suggest 
malignancy. 

PHYSICAL    SIGNS    OF   ULCER 

Physical  evidences  of  gastric  or  duodenal  ulcer  are  so  frequently 
lacking  that  their  absence  should  never  exclude  the  possibility  of  an 
ulcer  lesion  being  present.  Tenderness  and  other  physical  signs,  when 
elicited,  afford  only  confirmatory  proof. 

The  most  typical  physical  sign  is  localized  tenderness.  This  is 
usually  found  over  a  small  area  just  below  the  xiphoid,  or  midway 
between  the  xiphoid  and  the  navel,  corresponding  to  the  position  of 
the  celiac  ganglion.  In  duodenal  ulcers  the  tenderness  extends  some- 
what to  the  right,  although  for  unexplained  reasons  tenderness  in 
duodenal  ulcers  may  be  confined  entirely  to  the  left  hypochondrium. 
Care  should  be  taken  not  to  confuse  this  local  tenderness  with  the 
more  diffuse  tenderness  that  is  elicited  by  the  deep  palpation  of  the 
abdominal  aorta  in  thin  nervous  women  or  with  the  smaller  area  of 
localized  tenderness  in  the  median  line  due  to  small  epigastric  hernia. 

The  area  of  tenderness  affords  no  clue  whatever  to  the  localization 
of  the  ulcer. 

More  rarely  the  whole  epigastrium  is  diffusely  tender — a  sign  which 
is  devoid  of  any  diagnostic  value  whatever. 

Associated  with  the  tenderness  there  may  be  a  slight  amount  of 
localized  rigidity  of  the  abdominal  wall.  The  association  in  duodenal 
ulcer,  of  a  tender  area  2  to  3  inches  in  diameter  in  the  median  line  and 
to  the  right  just  above  the  navel,  with  slight  rigidity  of  the  upper 
portion  of  the  right  rectus  muscle,  and  a  heightened  epigastric  reflex 
on  that  side,  is  not  an  uncommon  one,  but  these  signs  are  often  lacking, 
or  present  only  during  the  period  of  greatest  pain.     Tenderness  is 


140  ACUTE  AND  CHRONIC   ULCER 

usually  most  marked  in  acute  ulcers  or  durius^  the  acute  exacerbations 
of  the  chronic  form.  In  these  acute  stages  of  ulceration  there  may  be 
found  a  zone  of  cutaneous  hyperesthesia  2  to  3  inches  in  breadth, 
starting  in  front  at  the  median  line  in  the  epigastrium,  and  following 
the  course  of  the  intercostal  nerves  to  the  back,  terminating  in  an 
intensified  area  of  sensitiveness  at  the  point  of  emergence  of  the  posterior 
nerve  filaments.  The  boundaries  of  this  zone,  described  by  Head,  are 
determined  by  gently  scratching  the  skin  with  a  pin  in  vertical  lines 
from  above  downward  and  then  from  below^  upward,  and  marking 
the  points  above  and  below  at  which  the  sensation  of  ordinary  scratch- 
ing passes  into  one  of  greater  intensity  of  pain,  often  likened  by  the 
patient  to  the  rubbing  of  an  abraded  surface.  This  area  of  hyper- 
esthesia is  not  distinctive  of  ulcer,  as  it  may  be  present  in  appendicular 
dyspepsia. 

A  dorsal  point  of  tenderness  first  described  by  Boas  may  be  found 
at  the  level  of  the  eleventh  and  twelfth  dorsal  vertebrte  a  little  to  the 
left  of  the  spinal  column,  having  a  lateral  expansion  of  2  or  3  cm.  and 
a  height  of  1  to  4  cm.  It  may  be  found  on  both  sides,  and  in  some 
cases,  especially  in  duodenal  ulcer,  according  to  Eisner,  the  dorsal 
point  may  be  present  only  to  the  right  of  the  median  line.  According 
to  Boas  it  is  present  in  one-third  of  all  cases  of  ulcer,  although  in  the 
writer's  experience  it  is  found  with  but  half  this  frequency.  It  is 
generally  more  common  with  ulcers  of  the  posterior  wall,  and  if  limited 
entirely  to  the  back,  it  may  be  of  the  greatest  diagnostic  importance. 
If  Head's  hyperesthetic  zone  is  j)resent  the  dorsal  point  marks  the 
posterior  limit  of  the  hypersensitive  area. 

In  acute  ulcer  there  is  no  tumor  mass  to  be  felt,  but  such  is  not  the 
case  in  many  instances  of  chronic  ulcer.  Callous  ulcers  with  thickened 
bases  may  be  palpable  tiirough  the  abdominal  wall,  as  may  those 
ulcers  which  have  contracted  adhesions  with  neighboring  parts.  The 
tumor  that  can  l)e  thus  pali)ated  may  so  closely  resemble  malignancy 
that  a  dificrciitial  diagnosis  is  impossible — in  fact  an  exact  diagjiosis 
may  only  be  determined  l)y  microscopical  examination.  In  the  cases 
that  have  come  to  operation  the  error  has  invariably  been  in  one 
direction,  that  is  to  say,  a  non-malignant  mass  was  believed  to  be 
cancerous. 

The  physical  signs  of  the  complications  will  l)c  described  under 
their  separate  headings. 

RADIOGRAPHY    OF    ULCER 

Were  it  a  fact  that  the  roiigliciictj  base  of  an  ulcer  regularly  retains 
its  bismuth  coating  after  tlie  rest   of  the  meal   had  left  the  stomach, 


RADIOGRAPHY  OF  ULCER  141 

the  radiographic  diagnosis  could  be  easily  and  definitely  established. 
Unfortunately  the  ordinary  crateriform  ulcer  does  not  retain  its  bismuth 
coating  for  any  longer  time  than  does  the  mucous  membrane  in  its 
vicinity,  so  that  we  are  not  furnished  with  any  definite  signs  that  it 
exists.  It  is  only  by  the  indirect  evidences  of  ulceration  that  we  may 
be  suspicious  of  its  presence.  These  signs  are  not  diagnostic  in  them- 
selves, so  that  a  decision  cannot  be  reached  by  the  study  of  the  plates 
alone;  it  is  only  by  the  combined  evidence  of  clinical  history,  physical 
examination,  gastric  analyses,  and  the  radiographic  plates  that  correct 
conclusions  can  be  drawn.  The  physician  has  no  right  to  expect  a 
diagnosis  to  be  made  for  him  by  a  radiologist  who  knows  nothing  more 
of  the  patient  than  can  be  learned  by  the  study  of  the  plates.  The 
physician  and  radiologist  must  work  in  conjunction  with  each  other, 
and  each  supplement  by  his  special  knowledge,  the  acquirements  of 
the  other. 

Radiological  Diagnosis  of  the  Stomach. — Technique. — Following  the 
teachings  of  Holzknecht  and  Haudek,  the  author  recommends  the 
following  as  a  routine  technique  in  all  stomach  examinations.  The 
patient  is  first  prepared  by  a  thorough  catharsis,  preferably  by  castor 
oil  given  at  night.  The  following  morning  at  a  prearranged  hour  the 
patient  takes  a  Rieder  meal  of  8  ounces  of  oatmeal  gruel  into  which 
is  thoroughly  mixed  2  ounces  of  bismuth  subcarbonate  or  bismuth 
oxychloride,  obtained  from  a  reputable  druggist,  so  that  the  drug  is  as 
pure  as  can  be  obtained.  A  light  breakfast  of  tea  and  toast  may  be 
given  one  hour  later.  The  patient  is  to  be  at  the  radiologist's  office 
five  and  one-half  hours  after  taking  the  Rieder  meal,  so  that  the  first 
radiograph  may  be  taken  exactly  six  hours  after  the  ingestion  of  the 
bismuth.  This  plate  will  show  the  motility  of  the  stomach  and  the 
location  of  the  head  of  the  bismuth  column  in  the  ileum  or  colon.  A 
second  bismuth  meal,  composed  of  bismuth  subcarbonate  or  oxychloride 
1|  ounces,  gum  acacia  mucilage  2  ounces  (=  33  per  cent,  gum  acacia), 
water  q.  s.  to  8  ounces,  is  then  given,  and  a  second  radiograph  imme- 
diately made,  which  in  its  turn  will  show  the  size,  shape,  and  position 
of  the  stomach.  There  are  now  in  the  two  plates,  as  a  rule,  sufficient 
radiological  data,  combined  with  the  history,  clinical  findings,  and 
appearance  of  the  patient,  to  make  a  diagnosis  of  the  case.  Occasion- 
ally a  third  radiograph  may  be  taken  fifteen  minutes  after  the  second 
as  a  control,  or  to  see  the  motility  of  pylorus  and  first  part  of  the 
duodenum.  Sometimes  in  cases  of  hypermotility  it  is  well  to  radio- 
graph the  patient  three  hours  after  the  ingestion  of  bismuth.  The 
patient  is  radiographed  standing,  although  additional  plates  may  be 
taken  in  the  recumbent  position  if  desired. 


142  ACUTE  AND  CHRONIC   ULCER 

Radiographic  Indications  of  Ulcer. — The  following  radiographic 
findings  may  be  considered  suspicious  of  ulcer: 

1 .  Bismuth  residue  in  the  stomach  six  hours  after  the  meal  indicates 
a  lack  of  motility  which  may  be  due  to  spasm,  tumefaction,  or  slight 
cicatricial  contracture  of  the  pylorus,  or  to  atony.  If  the  stomach 
show  a  normal  outline,  atony  may  be  excluded. 

Unfortunately  there  are  some  instances  of  pylorospasm  secondary  to 
chronic  appendicitis  or  irritative  lesions  of  the  gall-bladder,  in  which 
bismuth  remains  may  be  found  in  the  stomach  six  hours  after  the 
meal,  anfl  in  which  the  contour  of  the  stomach  is  normal,  so  that  by 
the  .T-ray  alone  a  differential  diagnosis  cannot  be  made.  Holzknecht 
lays  stress,  however,  upon  the  presence  of  tenderness  on  palpation  on 
a  spot  which  radiographically  corresponds  to  the  lesser  curvature  near 
the  pylorus,  and  which  shifts  its  position  according  to  the  varying 
positions  of  the  stomach.  It  is  of  the  greatest  service  carefully  to 
palpate  the  epigastrium  before  the  .r-ray  examination,  and  to  mark 
the  point  of  maximum  tenderness  by  a  small  bird-shot  applied  to  the 
spot  by  an  adhesive  strip. 

2.  A  displacement  of  the  pylorus  upward  and  to  the  left  is  not 
infrequent  with  ulcers  of  the  lesser  curvature,  which  cause  contraction 
along  the  upper  border  approximating  the  cardia  and  the  pyloric  end. 
The  resulting  shape  of  the  stomach  is  sometimes  spoken  of  as  the 
"snail  form."  The  last  portion  of  the  greater  curvature,  instead  of 
curving  upward  to  the  right,  will  be  drawn  perpendicularly  upward 
and  to  the  left,  giving  that  portion  of  the  stomach  the  undershot 
appearance  of  a  bull-dog's  jaw.  This  undershot  appearance  of  the 
greater  curvature  is  also  seen  with  pyloric  obstruction. 

3.  Hour-glass  contraction  that  appears  in  all  of  a  series  of  plates 
are  suggestive  of  old  cicatrizing  ulcer, 

A  spastic  hour-glass  contraction  is  frequently  seen  with  idcer  of  the 
lesser  curvature,  especially  if  adherent  to  the  under  surface  of  the 
liver.  There  is  a  contraction  or  drawing  in  of  the  greater  curvature,  as 
if  the  lower  border  were  pulled  up  at  this  point,  allowing  of  sagging 
on  either  side.  It  is  to  be  distinguished  from  a  peristaltic  Avave  bj^  the 
fact  that  the  indentation  appears  on  the  greater  curvature  only.  Spas- 
modic hour-glass  comes  and  goes,  is  present  on  some  plates  and  not 
on  others,  and  will  remain  unchanged  whether  the  i)atient  stands  or 
lies  down.  The  same  incisure  may  also  occur  on  the  lower  curvature 
from  spasm  originating  from  ulcer  of  the  lesser  curvature,  even  in  the 
absence  of  adhesions,  and  this  may  ap])ear  fixed  in  a  large  number  of 
plates.  A  similar  incisure  may  also  appear  in  the  plates  of  gastric 
cancer. 


PLATE    I 


Fig.   1 


Fiy.   2 


Fig.  1. — Ulcer  of  Lesser  Curvature,  Retraction  of  Lesser  Curvature,  draw- 
ing Pylorus  up  and  to  the  left.  The  so-called  "snail-form,"  described  by 
Haudek.       (Radiologist,    Dr.    Learning.) 

Fig.  2. — Ulcer  of  Lesser  Curvature  and  Pylorus.  The  typical  bowl- 
shaped  bismuth  residue  is  not  as  marked  as  is  usual,  although,  pyloric 
stenosis  exists.       (Radiologist,   Dr.    Busby.) 


Fig.    8 


Fig.   4 


Spasmodic     Incisure 


Greater 


Fig.     8. — Ulcer    of    Lesser     Curvature. 
Curvature.       (Radiologist,  Dr.   Busby.) 

Fig.   4. — Ulcer  of  Pylorus  with  Adhesions  and  Distortion,  Closely  Resem- 
bling Carcinoma.      (Radiologist,   Dr.   Busby.) 


RADIOGRAPHY  OF   ULCER  143 

Hertz^  has  shown  that  an  ulcer  of  the  lesser  curvature  adherent  to 
the  liver  may,  when  the  patient  stands,  produce  a  line  of  tension 
diagonally  downward,  or  up  the  greater  curvature  at  this  point,  while 
on  either  side  a  sagging  of  the  lower  border  may  appear,  causing  the 
semblance  of  an  hour-glass  stomach,  which  disappears  when  the 
patient  lies  down. 

4.  Distortion  or  displacement  of  the  stomach  by  adhesions  suggests 
ulcer  as  a  probable  cause. 

In  the  majority  of  cases  of  adhesions  following  ulcer,  the  region  of 
the  cap  and  pyloric  sphincter  are  jfirst  involved.  The  cap  looks  con- 
tracted, its  edges  are  ragged,  or  its  surface  worm-eaten,  showing  differ- 
ent degrees  of  density.  The  sphincter  may  appear  rough  and  indistinct 
in  outline  and  the  lumen  may  be  displaced  from  its  central  position. 

The  lesser  curvature  of  the  pyloric  portion  is  more  likely  than  the 
greater  curvature  to  be  involved,  so  that  the  indistinct  area  of  the 
sphincter  may  be  wedge-shaped,  the  broader  base  being  the  uppermost. 

Frequently  the  contour  of  the  stomach  will  reveal  the  identity  of 
the  adherent  viscus. 

Adhesions  to  the  gall-bladder  or  liver  generally  result  in  the  stomach 
lying  horizontally,  rather  than  in  the  normal  oblique  or  vertical  posi- 
tion. This  abnormality  must,  however,  be  present  in  all  plates  before 
any  inference  can  be  drawn. 

Adhesions  from  gall-bladder  infection  may  give  the  same  radio- 
graphic findings  as  those  due  to  ulcer,  although  in  many  instances 
suspicion  is  aroused  by  the  angulation  of  the  cap  to  the  right,  so  that 
the  lumen  runs  horizontally  instead  of  vertically.  The  cap  may  be 
contracted  and  irregular,  becoming,  as  the  adhesions  progress,  quite 
asymmetrical  and  ill-defined. 

Gallstones  are  only  infrequently  revealed  by  the  a;-ray,  but  occa- 
sionally calcareous  deposits  form,  so  that  they  may  be  recognized  and 
throw  considerable  light  upon  the  diagnosis. 

Adhesions  are  often  progressive,  so  that  successive  examinations 
should  be  made  at  intervals. 

The  diagnosis  of  adhesions  by  .-r-ray  is  not,  however,  quite  so  simple 
as  it  would  appear,  and  many  adhesions  are  supposed  to  exist  in  cases 
in  which  normal  conditions  are  found  at  exploration.  A  stomach  may 
appear  as  if  fixed  in  an  abnormal  position  and  stilly  may  be  proved  to 
be  freely  movable  by  changes  in  the  position  of  the  patient.  The 
Trendelenburg  position  is  often  serviceable  in  demonstrating  the 
mobility  of  a  stomach  that  at  first  may  seem  adherent. 

The  diagnosis  of  adhesions  cannot  be  made  on  the  evidence  of  one 

1  Lancet,  April  6,  1912. 


144  ACUTE  AND  CHRONIC   ULCER 

plate  alone.     Successive  examinations  must  be  made  and  the  findings 
must  be  constant. 

5.  A  small  puckered  area  in  which  the  rugse  are  distorted  is  suggestive 
of  gastric  ulcer.  If  the  area  be  large,  the  region  may  fail  to  expand 
and  contract  with  the  rest  of  the  organ.  It  is  even  more  suggestive 
when  the  localization  of  the  affected  area  coincides  with  that  of  local 
tenderness  on  palpation. 

6.  Haudek  makes  a  point  of  watching  for  an  upper  line  of  fluid  across 
the  stomach  after  a  liquid  bismuth  meal,  thus  indicating  hypersecre- 
tion. This  test  is  not  a  very  conclusive  one,  and  does  not  compare 
with  the  simpler  method  of  testing  for  hypersecretion  by  the  passage 
of  a  tube  in  the  fasting  state. 

7.  Fluoroscopy  may  show  at  times  a  reversed  peristalsis,  indicating 
an  extreme  degree  of  spasticity.    This  is  suggestive  but  not  conclusive. 

8.  The  radiographic  findings  of  ulcer  involving  the  patency  of  the 
pyloric  canal  resulting  in  stenosis,  will  be  described  under  the  latter, 
heading. 

Radiographic  Examination  of  Duodenal  Ulcer.— 1.  One  of  the  most 
characteristic  ai)pearances  is  an  upward  displacement  of  the  pyloric 
end  of  the  stomach  and  its  retention  by  adhesions,  so  that  the  stomach 
lies  obliquely,  or  even  horizontally,  rather  than  vertically.  The 
importance  of  this  finding  is  generally  acceded. 

2.  Fluoroscopy  may  demonstrate  intermittent  pyloric  contraction. 
The  stomach  may  start  to  empty  itself,  when  suddenly  pylorospasm 
occurs,  preventing  further  egress,  until  after  a  variable  time  the  spasm 
relaxes,  and  the  bismuth  is  again  forced  into  the  duodenum. 

3.  An  indentation  in  the  cap  caused  by  the  descent  at  one  side  of 
the  second  portion  of  the  duodenum  should  not  be  confused  with  a 
pathological  condition. 

4.  A  shadow  of  bismuth  visible  in  the  cap  five  or  six  hours  after  the 
ingestion  of  the  bismuth  meal  when  the  stomach  and  the  remainder 
of  the  duodenum  are  completely  e\acuated,  has  l)een  said  to  indicate 
the  presence  of  a  duodenal  ulcer. 

5.  Haudek  has  seen  with  the  fluoroscope,  sharp  contractions  of  the 
duoflenum  in  cases  of  ulcer,  but  considers  the  i)henomenon  exceedingly 
rare. 

6.  l{adiograi)liic  evidence  of  hy])erse('retion  should  suggest  the  possi- 
bility of  duodenal  ulcer. 

Radiographic  Diagnosis  of  Penetrating  or  Perforating  Ulcer. — 
When  an  ulcer  lias  extended  through  the  wall  of  the  stomach  and 
opens  into  a  cavity  limited  by  adhesions,  or  perforates  into  the  liver 
or  pancreas,  definite  and  convincing  evidence  may  be  obtained  by  the 
x-ray.     Six  hours  after  the  ingestion  of  the  first  bismuth  meal  there 


PLATE    II 


Fig.    1 


Duodenal  Ulcer,  after  Perforation.     Stomach  distorted  and   misshapen 
by  adhesions.       (Radiologist,  Dr.  Le  Wald.) 


Fig.   2 


Ulcer  of  the  Duodenuni,  sliowing  Transversely  Lymg  Stomach,  with 
Duodenuni  far  to  the  Right  of  the  Type  Described  by  Holzkneelit.  (Radi- 
ologist,  Dr.   Busby.) 


PLATE    III 


Fig.   1 


Uleer  of  Lesser  Curvature  Penetrating  into  the  Liver.  Noteworthy  is  the 
isolated  bismuth  residue  above  the  line  of  lesser  curvature,  surmounted 
by  an  air-bubble.  (Operator,  Dr.  George  E.  Brewer;  radiologist,  Dr. 
Leaming.) 


Fig.   2 


Fig.   8 


Fig.  2. — Six-hour  Plate  of  Uleer  of  the  Duodenuni  Penetrating  into  the 
Pancreas.  Noteworthy  are  the  bismuth  residue  in  the  stomach  and 
the  isolated  bismuth  residue  in  the  false  cavity  surmounted  by  an 
air-bubble.     (Operator,  Dr.  Charles   H.  Peck;    radiologist,   Dr    Leaniing.) 

Fig.  8. — Penetrating  Ulcer,  with  Large  Cavity  in  the  Liver.  Hour-glass 
Contraction.  Pylorus  Free.  Bisniuth  Residue  after  Six  Hours.  (Drawn 
from  Holzknechfs  article,  Archives  of  the  Roentgen  Ray,  April,  1912,  p.  67.) 


PROGNOSIS  AND  END-RESULTS  145 

may  be  seen  a  small  isolated  patch  of  bismuth,  usually  of  a  half-moon 
shape,  often  surmounted  by  an  air  bubble,  which  j)ersists  after  the 
complete  evacuation  of  the  stomach.  When  the  examination  is  made 
immediately  after  the  filling  of  the  stomach  with  bismuth  suspension 
fluid,  the  patch  is  often  seen  just  outside  of  the  contour  of  the  stomach 
wall.  These  findings  are  well  illustrated  in  the  accompanying  plates. 
Such  a  diagnosis  of  perforative  ulcer  by  .r-rays,  according  to  Holz- 
knecht,^  is  not  unusual,  for  he  reports  that  Haudek  has  met  with  28 
cases  of  this  variety,  the  diagnosis  being  confirmed  in  15  instances. 
In  many  of  these  cases  there  was  an  absence  of  hydrochloric  acid  in 
the  gastric  juice. 

PROGNOSIS    AND   END-RESULTS 

Prognosis. — The  prognosis  of  gastric  and  duodenal  ulceration  both 
as  regards  the  percentage  of  mortality  and  of  the  curative  effect  of 
treatment  is  extremely  difficult  to  determine.  A  mass  of  statistics  is 
available,  but  in  many  respects  they  are  often  both  insufficient  and  mis- 
leading. This  applies  both  to  the  reports  of  medical  and  of  surgical  cases. 

Immediate  Prognosis  under  Medical  Treatment. — Medical  statistics  are 
especially  lacking  in  accuracy  for  the  following  reasons: 

1.  When  a  surgeon  operates  upon  a  patient,  he  sees  an  ulcer  and 
recognizes  it  as  such.  The  physician,  on  the  other  hand,  who  makes 
his  diagnosis  without  the  benefit  of  such  palpable  and  visible  evidence, 
may  or  may  not  be  correct  in  his  conclusions.  Many  cases  are  treated 
as  ulcers  that  are  really  suffering  from  chronic  appendicitis  or  gall- 
bladder disease.  A  few  years  ago  the  writer,  wishing  to  trace  the 
end-results  of  ulcers  treated  by  him,  w^rote  a  series  of  letters  to 
those  cases  only  in  which  the  diagnosis  seemed  certain.  12  per  cent, 
of  replies  were  to  the  effect  that  after  the  ulcer  cure  the  symptoms 
had  improved  but  had  not  ceased  until,  after  an  attack  of  appendicitis, 
the  removal  of  the  appendix  had  been  followed  by  an  entire  and  perma- 
nent cessation  of  gastric  symptoms.  This  bitter  experience  has  never 
been  forgotten. 

While  this  inclusion  of  cases  resembling  ulcer  but  incorrectly  diag- 
nosticated does  not  add  to  the  percentage  of  mortality,  but  probably 
rather  to  the  apparent  reduction  of  the  death  rate,  nevertheless  it  is 
obvious  that  it  materially  reduces  the  number  of  cases  that  are  neither 
improved  nor  cured  by  the  ulcer  treatment. 

12  to  15  per  cent,  of  all  cases  diagnosticated  as  ulcer  give  disappointing 
end-residts  because  of  this  error  in  diagnosis. 

^  Archives  of  Rontgen  Raj's,  July,  1912. 
10 


146  ACUTE  AND  CHRONIC   ULCER 

2.  The  prognosis  is  diflFerent  according  to  whether  the  figures  are 
compiled  from  private  or  from  hospital  sources. 

In  hospital  cases  the  mortality  is  naturally  greater,  because  of  the 
greater  severity  of  the  cases  admitted  and  of  the  larger  proportion  of 
cases  entering  with  severe  hemorrhage  or  perforation.  Of  100  con- 
secutive cases  of  ulcer  admitted  to  Bellevue  Hospital  and  compiled  by 
the  writer,  17  per  cent,  were  admitted  with  hemorrhage  and  7  per 
cent,  with  perforation. 

The  end-results  of  treatment  are  very  different  in  the  two  classes. 
For  medical  treatment  to  effect  results  in  chronic  ulcer,  it  should  be 
continued  for  a  long  period  of  time,  even  after  the  cessation  of  actual 
symptoms.  Hospital  cases  remain  in  the  wards  just  as  long  as  they 
suffer  pain — and  leave  as  soon  as  they  are  fairly  comfortable,  returning 
to  a  promiscuous,  unsuitable  diet,  and  a  disregard  of  all  medical  con- 
ventions. No  Avonder  so  many  are  unimproved  and  no  wonder  so 
many  relapses  occur.  It  is  only  after  alarming  hemorrhage  that  many 
of  the  hospital  patients  will  undergo  any  treatment  at  all. 

The  comparatively  small  number  of  perforations  which  occur  in 
patients  who  have  had  ulcer  treatment  because  of  hematemesis  shows 
the  beneficial  effects  of  medical  treatment,  even  if  it  be  inadequate 
to  effect  a  permanent  cure. 

The  differences  between  hospital  and  private  cases  are  well  shown 
by  the  following  tables  arranged  by  Musser: 

Simple   Ulcer  without  Complications,   from   General   Sources — 409  Cases 

Cured.  Improved.  Unimproved.        Died. 

Per  cent.  Per  cent.        Por  rent.         Per  cent. 

Treated  medically  .      .      .      .     73  3  7.9  6.4  12.4 

Treated  surgically  .      ...      68.1  5.1  6.6  20.0 

The  total  mortality  of  medical  and  surgical  cases  was  17.3  per  cent. 

Similar  ri/ERs  Treated  in  Private  Practice — 194  Cases 

Cured.  Improved.    Unimproved.         Died. 

Per  rent.  Per  eent.         Per  cent.         Per  cent. 

Treated  medically  .      ...      60.1  32.0  ,5.0  3.1 

Troatod  surgically  .      ...      77.1  8.5  2.9  11.4 

l'\)r  a  very  complete  and  interesting  series  of  statistics  the  reader  is 
referred  to  IMusser's  article.' 

3.  It  is  recognized  that  siinj)h'  iicutc  ulcers  usually  heal  readily 
under  medical  treatment,  and  that  in  these  cases  the  prognosis,  as  a 
rule,  is  good.     Chronic  ulcers,  with  or  without  comi)lications  such  as 

'  Anicr.  .Jour.  .Med.  Sci.,  Doccnihcr,  1907,  cxxxv,  781, 


PROGNOSIS  AND  END-RESULTS  147 

pyloric  narrowiiifj,  hour-fi^lass  contractions,  and  extensive  adhesions, 
are  more  intractable  and  frequently  require  operative  interference.  To 
bring  these  two  classes  of  cases  together  in  one  compilation,  naturally 
gives  results  that  are  erroneous  and  misleading.  It  is  not  surprising, 
therefore,  that  the  death  rate  should  be  so  \'ariously  estimated,  the 
j)ercentages  running  in  a  long  series  from  1  to  50  per  cent.  It  is,  how- 
ever, generally  conceded  that  while  in  hospitals  the  death  rate  may  be 
as  high  as  20  per  cent.,  according  to  the  class  of  patient  admitted,  the 
average  percentage  of  mortality  is  not  far  from  10  per  cent.  Musser, 
from  a  large  compilation  of  statistics,  estimates  that  about  8  per  cent, 
of  ulcer  patients  die  as  a  result  of  the  disease. 

When  the  medical  treatment  can  be  carried  out  the  results  in  indiv- 
idual hands  may  be  somewhat  less.  Von  Leube,  whose  skill  in  the 
treatment  of  ulcer  is  well  recognized,  lost  but  2.4  per  cent,  of  a  total 
number  of  556  cases  treated  by  him.  In  the  writer's  experience,  the 
mortality  of  ulcers  seen  in  private  practice  amounted  to  3.1  per  cent. 
In  hospital  practice,  excluding  those  cases  in  which  the  cause  for  death 
was  an  intercurrent  disease  not  associated  in  any  way  with  chronic 
ulceration  (3  cases  of  acute  lobar  pneumonia,  1  of  chronic  nephritis 
and  uremia,  and  1  from  arterial  sclerosis  and  senility,  in  all  of  which 
cases  a  chronic  ulcer  was  found  which  had  not  given  symptoms  during 
life)  the  ulcer  caused  death  in  11.1  per  cent.  The  general  mortality 
of  both  private  and  hospital  cases  amounted  to  a  little  less  than  7 
per  cent.    These  figures  are  identical  with  those  of  Musser. 

Estimates  of  Mortality  in  Ulcer  Medically  Treated 

Per  cent. 

Hewes 2.0 

Robinson 2.1 

Russell 2.1 

Von  Leube  (556  cases) 2.4 

Musser,  private  sources 3.1 

Lockwood,  private  sources 3.1 

Schultz,  Breslau,  and  New  Hamburg  Hospitals 5.4 

Greenough  and  Joslin,  Massachusetts  General  Hospital             .  8.0 

Lockwood,  hospital  cases 11.1 

Musser,  hospital  cases 12.4 

Hawkins,  St.  Thomas'  Hospital 13.3 

Welch 15.0 

Sears,  Boston  City  Hospital 21.0 

Thompson 20.5 

Robson  (estimated) 25.0 

Musser,  both  hospital  and  private  cases    ........  8.0 

Lockwood,  both  hospital  and  private  cases 7.0 

Average  mortality  in  l)oth  liospital  and  private  cases  generally 

conceded ■  S  to  10.0 


148 


ACUTE  AND  CHRONIC   ULCER 


Immediate  Prognosis  under  Surgical  Treatment. — The  results  of  oper- 
ation for  gastric  ulcer  are  far  better  in  the  case  of  a  few  experienced 
operators  than  the  larger  number  of  operations  performed  by  the 
surgical  profession  at  large. 

The  figures  of  some  surgeons  show  a  remarkably  low  rate  of  mor- 
tality.   The  following  table  is  given  by  Deaver: 


Statistics  of  Operations  for  Benign   Diseases  of  the   Stomach 


Operator. 

Crile    .      .      . 

Czerny 

Deaver 

Hartmann 

Helferich 

Hochenogg 

Kvause 

Mayo 

M  orison    . 

Moynihan 

Power,  D'Arcy 

Robson,  Mayo 

Rotgans    . 

Schou 

Schloffer  . 


Number  of 

Mortality 

Dat 

e. 

operations. 

Deaths. 

Per  cent 

1908 

56 

1 

1.7 

1902 

83 

4 

4.8 

1900- 

1907 

91 

8 

8.7 

1903- 

1905 

47 

3 

6.3 

1905 

86 

7 

8.1 

1906 

94 

6 

6.4 

1906 

55 

5 

9.0 

1906 

307 

19 

6.2 

1905 

27 

1 

3.7 

1906 

334 

21 

6.2 

1906 

41 

•  3 

7.3 

1906 

322 

10 

3.1 

1906 

5.0 

1907 

54 

3 

5.5 

1906 

53 

2 

3.8 

Mayo,  in  19()(),  had  a  series  of  1()7  gastro-enterostomies  with  only 
one  death.  ]\layo  Robson  reported  2  deaths  in  112  gastrojejunostomies 
for  benign  disease.  Moynihan,  in  1906,  reported  248  cases,  with  only 
2  deaths,  a  mortality  of  only  0.8  per  cent.  There  had  been  no  deaths 
among  the  last  151  cases. 

In  1000  cases  of  different  types  of  ulcer  treated  surgically  by  W.  J. 
and  C.  H.  Mayo'  by  all  varieties  of  operation,  the  immediate  mortality 
was  2.4  per  cent. 

At  the  same  time  it  must  be  noted  that  the  mortality  of  operations 
done  by  less  experienced  surgeons  is  far  greater  than  this. 

French  reports  from  Guy's  Hospital  a  mortality  of  23.4  per  cent.; 
in  St.  Bartholomew's  Hospital  the  deaths  after  operations  were  17.1 
per  cent.;  of  150  benign  cases  quoted  by  Bcttman  and  White,  the 
immediate  mortality  was  10  per  cent.  jNlusser's  figures  of  operations 
done  for  simple  uncomplicated  ulcer  show  that  11.4  per  cent,  were 
fatal  in  private  practice,  20  per  cent,  in  hospital  cases. 

Hall"  reports  0  deaths  in  50  of  his  cases  operated  upon  by  various 
surgeons — a  mortality  rate  of  12  per  cent. 

'  Annals  of  Surgery,  September,  1911. 
^  Amer.  Jour.  Med.  Sci.,  cxxxvii,  625. 


PROGNOSIS  AND  END-RESULTS  149 

A  series  of  figures  published  by  Hartmann  show  how  the  danger  of 
operations  diminishes  with  the  increasing  skill  and  experience  of  the 
operator. 

His  first  series  of  operations,  comprising  21  gastro-enterostomies, 
with  5  deaths,  gave  a  mortality  of  23.7  per  cent.  His  second  series 
consisted  of  34  gastro-enterostomies  with  3  deaths — a  mortality  of  8.8 
per  cent.,  while  his  last  series  included  47  gastro-enterostomies  with  3 
deaths,  showing  a  mortality  of  6.3  per  cent. 

These  figures  show  how  important  it  is  for  the  physician  in  charge 
of  an  ulcer  case  requiring  surgical  interference  to  choose  as  his  confrere 
an  operator  of  known  skill  and  experience  in  gastric  surgery. 

End-results  of  Medical  and  Surgical  Treatment. — End-results  of 
Medical  Treatment. — It  is  difficult  to  arrive  at  satisfactory  conclusions 
by  a  study  of  the  statistics  available,  because,  as  a  rule,  the  patients 
have  not  been  followed  long  enough  to  determine  whether  or  not  the 
ulcer  has  actually  healed.  The  relief,  or  even  the  total  cessation  of 
symptoms,  should  not  bring  an  erroneous  belief  that  the  ulcer  is  healed 
and  the  patient  cured,  for  in  many  of  the  patients,  even  in  those  who 
conscientiously  carry  out  the  instructions  of  their  physician,  symptoms 
of  ulcer  sooner  or  later  reappear,  and  the  relapse  may  be  as  serious  as 
was  the  original  attack. 

How  long  a  time  of  freedom  from  symptoms  must  elapse  after 
treatment  before  the  patient  can  be  declared  cured  is  an  arbitrary 
one,  but  it  may  be  said  that  two  years  at  least  must  elapse  without 
symptoms  before  any  conclusions  can  be  drawn. 

It  is  more  difficult  to  trace  hospital  patients  than  those  seen  in 
private  practice,  but  when  they  can  be  followed,  it  will  be  found 
that  relapses  are  much  more  frequent  than  in  those  whose  mode  of 
life  and  intelligence  guard  them  from  the  obvious  faults  of  living 
which  militate  against  those  in  the  lower  walks  of  life.  The  longer 
the  patients  are  followed  the  greater  the  number  of  medical  failures 
that  become  evident.  No  value  can  be  attached  to  the  reports  of  cases 
that  are  not  followed  for  at  least  two  years.  It  may  be  said,  from  a 
study  of  statistics  that  conform  to  scientific  requirements,  that  under 
medical  treatment,  about  80  per  cent,  of  cases  are  apparently  cured, 
and  that  in  about  one-half  of  these  the  symptoms  of  ulcer  again  become 
manifest. 

Greenough  and  Joslin  found  in  the  Massachusetts  General  Hospital 
that  while  82  per  cent,  of  ulcers  were  discharged  as  "cured"  or 
"relieved,"  but  40  per  cent,  remained  well.  Sears  estimates  the  number 
of  medical  failures  after  five  years  at  50  per  cent.  Mumford  and  Howe 
estimate  80  per  cent,  of  apparent  cures,  of  which  one-half  relapse. 
Hewes  in  51  cases  found  48  apparently  cured.     In  two  years  63  per 


150  ACUTE  AND  CHRONIC  ULCER 

cent,  of  these  remained  well.  Paterson  in  72  hospital  cases  discharged 
cured  found  that  but  19  remained  well,  7  were  doubtful,  40  were  still 
suffering,  5  had  undergone  surgical  treatment  for  their  complaint,  and 
1  had  died. 

7/1  aboid  20  per  cent,  the  immediate  result  is  not  brilliant,  a  certain 
amount  of  distress  still  remaining,  although,  as  a  rule,  the  patients  are 
f)enefited  to  a  greater  or  less  extent  by  their  treatment.  The  number 
of  those  who  show  no  improvement  whatever  is  relatively  small,  prob- 
ably not  over  5  or  G  per  cent.  It  is  probable  that  many  of  these  improved 
or  unimproved  cases  are  not  ulcers  at  all. 

In  1897  von  Leube,  in  a  communication  before  the  Thirteenth 
Surgical  Congress,  announced  that  whereas  the  former  mortality  of 
ulcer  had  been  as  high  as  13  per  cent.,  the  enforcement  of  the  rigid 
treatment  inaugurated  by  him  had  been  promptly  followed  by  a 
marked  reduction  in  the  death  rate.  Of  556  cases  reported  by  him, 
74.1  per  cent,  could  be  considered  cured,  21.9  per  cent,  improved,  1.6 
per  cent,  unimproved,  2.4  per  cent,  had  died. 

In  the  year  1909  he  has  given  the  total  of  his  later  results  to  date,^ 
and  they  show  a  surprising  improvement  over  previous'  records. 

Of  627  cases  both  of  ulcers  with  hemorrhage  and  of  those  without, 
treated  in  the  previous  eleven  years,  in  his  clinic  and  in  his  private 
practice,  566,  or  90  per  cent.,  were  clinically  cured,  76  per  cent,  within 
four  weeks,  14  per  cent,  in  a  period  longer  than  this;  53,  or  8.5  per 
cent.,  were  improved;  6,  or  1  per  cent.,  remained  unimproved,  and  2, 
or  0.3  per  cent.,  died  as  the  result  of  hemorrhage. 

Tabulating  his  ulcers  that  were  attended  by  hemorrhage  he  found, 
that  72,  or  90  per  cent.,  were  clinically  cured  (66  per  cent,  within  five 
weeks,  24  per  cent,  in  a  longer  period  of  time  than  this) ;  5,  or  6.25  per 
cent.,  improved;  1,  or  1.25  per  cent.,  remained  unimproved,  while  2,  or 
2.5  per  cent.,  died. 

These  are  astounding  results.  The  writer,  however,  makes  use  of 
the  term  "clinically  cured,"  because  von  Leube  states  in  his  communi- 
cation that  he  regards  as  "cured"  those  cases  in  which  the  symptoms- 
disaj)j)ear  for  a  period  of  three  weeks,  and  in  which  ordinary  hospital 
diet,  not  especially  prescribed  ft)r  gastric  cases,  but  given  to  those 
whose  digestion  is  good,  is  eaten  without  discomfort.  He  notes  that 
occasionally  an  ulcer  is  only  ai)parently  cured,  and  that  after  a  longer 
or  shorter  time  pain,  dyspepsia,  and  hemorrhage  may  reappear,  but 
in  his  experience  such  a  relaj)se  occurs  only  in  very  rare  ex('ej)tioiis. 

It  is  unfortunate  that  von  Leube  has  not  followed  up  his  cases  for 
two  years  or  more,  and  gi\('n  us  the  end-results  thus  obtained.     The 

»  Deutsch.  iiicd.  Wcx-li.,  Juno  3,  1909,  No.  22. 


PROGNOSIS  AND  END- RESULTS  151 

writer's  experience  leads  liim  to  believe  thut  under  a  rigid  ulcer  cure 
fully  90  per  cent,  of  cases  may  be  considered  "cured"  in  the  sense  in 
which  that  term  is  used  by  von  Leube,  but  is  not  so  optimistic  as  to 
the  after-results  of  treatment. 

Of  the  ulcer  cases  treated  by  the  writer  by  a  rigid  and  thorough 
ulcer  cure,  and  followed  for  over  three  years,  the  following  data  may 
be  given: 

Permanently  cured 50.0  per  cent. 

Temporarily  cured  but  relapsed 16.6  per  cent. 

Improved 22 . 2  per  cent. 

Unimproved 5.5  per  cent. 

Died 5.7  per  cent. 

Of  the  22.2  per  cent,  improved  and  5.5  per  cent,  unimproved,  a 
total  of  27.7  per  cent.,  it  is  probable  that  at  least  half  were  suffering 
from  appendicular  dyspepsia  rather  than  ulcer,  or  from  a  combination 
of  chronic  ulcer  and  chronic  appendicitis.  Twelve  per  cent,  of  the 
writer's  cases  of  ulcer  that  did  not  improve  by  medical  treatment  were 
finally  cured  by  appendectomy.  It  is  reasonable  to  conclude  that 
many  who  were  not  ultimately  operated  on  were  nevertheless  cases 
of  this  description.  Unfortunately,  only  operation  or  autopsy  can 
decide.  The  causes  for  death  in  the  5.7  per  cent,  were  various  and 
largely  due  to  intercurrent  disease,  as  would  be  expected,  for  many  of 
the  cases  had  been  traced  for  ten  years  or  more.  The  exact  data  cannot 
be  given,  as  in  many  instances  the  cause  for  death  could  not  be  ascer- 
tained. It  is  a  fact,  however,  that  very  few,  if  any,  died  from  stomach 
disorders,  and  that  cancer  did  not  seem  to  be  the  cause  for  death  in 
any  of  the  cases  that  could  be  traced. 

The  immediate  results  of  treatment  were  satisfactory  in  much 
greater  proportions  than  these.  If  we  should  add  the  end-results  of 
the  ulcer  treatment  as  applied  to  those  whose  complaint  is  really 
chronic  appendicitis,  or  gall-bladder  disease,  that  have  been  erroneously 
diagnosticated  as  ulcer,  the  proportion  of  the  cases  entered  on  the 
case  books  as  "improved"  would  be  far  greater. 

End-results  of  Surgical  Treatment. — Owing  to  the  great  advances  made 
in  recent  times  in  gastric  surgery,  and  the  large  number  of  patients 
operated  upon,  only  a  few  can  give  a  postoperative  history  of  sufficiently 
long  duration  to  be  authoritative  as  to  ultimate  results.  It  must  be 
conceded,  however,  that  in  no  other  field  of  operative  work  have  more 
brilliant  results  been  effected,  both  as  regards  degree  of  improvement 
and  permanency  of  cure.  Writing,  however,  under  the  excitement 
of  their  successes,  it  is  possible  that  too  much  has  been  claimed  for 
surgery. 


152  ACUTE  AND  CHRONIC   ULCER 

Deaver  writes:  "Surgery  allows  95  to  98  per  cent,  of  patients  to 
recover,"  and  at  the  same  time  publishes  the  following  table  of  surgical 
end-results,  in  which  the  average  cure  is  but  86  per  cent. : 

End  Results  of  Operations  for  Benign  Diseases  of  the  Stomach 

Operator.  Cases  tiaced.    Cured.  Per  cent. 

Mayo  (1908) 234  189  80.7 

Moynihan  (1908) 247  211  85.42 

Czerny  (1902) _53  44  83.0 

Robson 96  89  92.7 

Deaver  (1900-1907) 64  49  76.5 

Deaver  (1905-1907) 31  26  83.87 

Paterson  (collective  statistics)        ...  116  109  93.9 

Helferich  (1905) 56  41  73.3 

In  Deaver's  own  cases^  that  were  traced,  only  58  per  cent,  had  no 
gastric  symptoms  after  operation,  14  per  cent,  were  markedly  improved, 
6  per  cent,  were  unimproved,  while  14  per  cent,  had  died,  either  from 
the  original  gastric  lesion  (2  probably  from  cancer)  or  from  some 
late  complication,  such  as  intestinal  obstruction,  or  vicious  circle, 
indirectly  caused  by  the  stomach  condition.  If  we  include  in  the 
surgical  statistics  the  results  of  operative  treatment  administered  by 
surgeons  of  less  experience  and  skill,  the  showing  is  certainly  not  as 
nnich  in  favor  of  surgical  intervention  as  we  have  been  led  to  suppose. 

Bettmann  and  White  found  that  of  126  cases  who  survived  the 
operation  (10  per  cent,  having  died  as  an  immediate  result  of  the 
operation),  and  who  were  under  observation  for  a  year  or  more,  only 
64.3  per  cent,  remained  well,  6.3  per  cent,  were  much  better,  while 
24.7  per  cent,  reported  as  little  or  no  better. 

Paterson,  by  tracing  the  history  of  116  patients  who  had  been  oper- 
ated upon  by  gastro-enterostomy  at  periods  varying  from  two  to 
nineteen  years,  concludes  that  but  85  per  cent,  are  permanently  cured. 
It  is  believed  by  the  writer  that  even  under  skilled  surgical  treatment 
this  latter  figure  or  even  a  little  less  will  be  nearer  correct  than  the 
higher  estimates  given,  that  8  to  10  per  cent,  will  die  directly  or  indirectly 
from  their  oiH-ration,  and  that  at  least  an  vq\u\\  number  will  derive 
no  benefit  from  their  treatment. 

W.  J.  Mayo  has  made,  however,  an  important  distinction  between 
the  surgical  end-results  of  ulcers  near  the  i)ylorus  and  those  of  the 
body  of  the  .stomach,  the  imi)()rtance  of  which  cannot  be  overstated. 

Basing  his  conclusions  on  a  series  of  lOOO  cases  of  ulcer  operated  on 
by  himself  and  C  II.  Mayo,  his  conclusions  are  that  the  treatment 
of  all  duodenal  and  all  obstructing  ulcers  of  the  pyloric  end  of  the 

'  Deaver  and  Aslihiust,  Siirj^ery  of  the  Uj)i)('r  .Vbdomen,  i,  108. 


'  COMPLICATIONS  OF   ULCER  153 

stomach  by  gastrojejunostomy  and  excision  or  infolding  the  ulcer 
gives  98  per  cent,  of  cures  or  great  improvement,  while  85  per  cent, 
of  ulcers  of  the  body  of  the  stomach  will  be  cured  or  greatly  relieved 
by  excision  or  devitalizing  suture  compression  with  gastrojejunostomy 
with  or  without  closure  of  the  pylorus.  The  remaining  15  per  cent, 
were  all  more  or  less  benefited.  None  were  made  worse  by  the  operation. 
The  series  was  terminated  January  17,  1911. 


COMPLICATIONS    OF   ULCER 

The  Malignant"  Degeneration  of  Chronic  Ulcers. — The  possibility 
of  carcinomatous  change  in  chronic  gastric  ulcers  is  of  great  interest 
pathologically,  and  of  very  great  importance  from  a  clinical  standpoint. 
That  such  changes  do  occur  is  well  recognized.  The  frequency  of 
such  transitions  is  more  fully  discussed  on  page  223. 

The  older  observations  were  practically  all  made  upon  postmortem 
material.  Such  material  is  notoriously  unreliable  for  such  study,  as 
the  process  is  generally  so  far  advanced  that  all  of  the  earlier  changes 
are  obliterated,  and  one  generally  finds  only  a  mass  of  carcinomatous 
tissue  in  one  or  other  portion  of  which  there  is  an  ulcer.  It  is,  indeed, 
often  impossible  to  tell  from  what  portion  of  the  stomach  wall  the 
tumor  took  its  origin.  There  may  be  one  large  ulcer  with  a  scar  tissue 
or  necrotic  base,  or  several  smaller  ones,  and  quite  often  it  seems 
reasonably  certain  that  these  ulcers  represent  secondary  loss  of 
substance   in  a  primary  carcinoma. 

The  more  recent  investigations  have,  for  the  most  part,  been  carried 
on  with  specimens  removed  at  operation,  and  it  is  to  such  material 
that  we  must  turn  for  a  correct  appreciation  of  the  pathological  changes 
involved.  Nearly  all  of  Wilson  and  MacCarthy's  work  was  done  with 
this  surgical  material,  and  from  their  extensive  observations  they 
believe  that  it  is  possible  for  one  to  recognize  the  following  changes 
in  sequence. 

"1.  Chronic  ulcers,  from  the  centres  of  which  the  mucosa  has 
disappeared,  leaving  a  scar-tissue  base. 

"2.  In  the  overhanging  borders  of. the  ulcers  the  mucosa  is  pro- 
liferating. 

"3.  Deep  in  the  borders,  many  groups  of  epithelial  cells  have  been 
nipped  off  by  scar  tissue  and  are  exhibiting  all  stages  of  aberrant 
proliferation  with  infiltration  of  the  surrounding  tissues. 

"4.  Metastases  are  forming  in  the  lymphatics  of  the  stomach  wall 
and  adnexa." 


154  ACUTE  AND  CHRONIC   ULCER 

Stages. — Menetrier,  as  a  result  of  his  studies  in  1900,  gives  his 
theory  of  carcinomatous  change  in  chronic  ulcers  in  the  following 
stages  (Deaver  and  Ashhurst) : 

"First  Stage:  This  is  purely  inflammatory.  There  is  a  chronic 
gastritis,  and  the  cells  lining  the  glands  lose  their  special  and  distinc- 
tive features  (the  histological  picture  is  simplified),  and  the  'acid' 
cells  disappear. 

"Second  Stage:  Adenomatous  in  character.  The  proliferating  glands, 
deprived  of  their  characteristic  elements,  become  more  contorted  and 
convoluted;  their  cells  increase  in  number;  cysts  form  as  a  result  of 
obstruction  of  the  gland  ducts  by  proliferation  of  their  lining  cells. 

"Third  Stage:  Epitheliomatous  in  character.  The  cell  groups  break 
through  the  muscularis  mucosse,  and  finally  are  found  lying  free  among 
the  connective  tissue  of  the  gastric  wall." 

On  gross  examination  of  some  of  the  ulcers  it  is  difficult  to  say 
whether  there  has  been  any  malignant  change.  They  appear  as 
ordinary  chronic  ulcers,  with  indurated  borders,  generally  showing 
an  abrupt,  somewhat  undermined  margin  with  overhanging  mucosa 
proximally,  with  a  more  gradually  sloping  wall  toward  the  pylorus. 
In  other  ulcers  in  which  such  a  transition  is  taking  place,  the  changes 
are  more  apparent  to  the  eye.  In  the  first  place,  these  ulcers  are  apt 
to  be  larger.  ]\Iayo  believes  that  most  ulcers  which  are  larger  than  a 
twenty -fi\-e  cent  piece  are  undergoing  malignant  degeneration.  While 
they  may  maintain  roughly  the  form  mentioned  above,  one  usually 
finds  more  extensive  induration  about  the  ulcer,  with  thickening  of 
the  stomach  walls,  and  commonly  a  definite  tumor  mass.  The  ulcer 
base  is  generally  composed  of  scar  tissue. 

jNIicroscopically,  the  first  changes  consist  of  small  islands  or  alveoli 
of  epithelial  cells  deep  down  in  the  mucosa,  cut  oft'  from  the  glandular 
epithelium  by  more  or  less  inflammatory  tissue.  These  areas  are 
usually  found  in  the  margins  of  the  ulcer,  and  from  these  isolated 
islands  of  cells  aberrant  and  atypical  epithelial  proliferation  may 
arise. 

A  little  later  change  shows  these  isolated  groups  of  cells  actively 
l)r()liferating,  but  still  more  or  less  confined  within  normal  bovuidaries. 
in  another  portion  of  the  same  ulcer,  or  in  another  ulcer  slightly  more 
advanced  in  its  malignant  transition,  the  i)r()liferating  cells  may  be 
seen  pushing  their  way  through  the  nuiscularis  mucosae  into  the 
submucosa. 

From  this  stage  it  is  but  a  step  to  a  typical  carcinomatous  picture 
of  actively  proliferating  cords  and  islands  of  cells  invading  the  sur- 
rounding tissues  in  an  atypical  and  lawless  manner.  In  these  well- 
marked  cases,  the  tyj)e  of  growth   ma\'  be  adenomatous,  scirrhous,  or 


COMPLICAriONH  OF   ULCER  loo 

may  occasionally  show  colloid  dejijeneration.  ( "arel'ui  examination 
will  almost  always  reveal  changes  in  both  the  i)roximal  and  distal 
margins  of  the  ulcer. 

Development  of  Malignant  Changes. — Stromeyer/  working  under 
Aschoff's  direction,  has  recently  reported  the  results  of  his  investiga- 
tions upon  the  association  of  chronic  gastric  ulcer  and  carcinoma. 
He  does  not  deny  the  possibility  of  a  carcinoma  developing  secondarily 
in  the  margin  of  an  ulcer.  In  fact,  one  of  his  cases  apparently  showed 
such  a  transition  in  a  very  early  stage.  However,  he  believes  that  in 
the  large  majority  of  cases  the  ulcer  represents  a  secondary  process 
in  a  primary  carcinoma.  His  material  was  obtained  partly  at  autopsy 
and  partly  at  operation. 

He  finds  that  in  practically  all  of  his  cases  there  is  cancer  develop- 
ment in  both  the  proximal  and  distal  walls  of  the  ulcer.  Superficially, 
it  extends  only  a  few  millimeters  outward  from  the  ulcer.  In  the 
submucosa  it  is  more  marked,  while  in  the  base  of  the  ulcer  it  is  most 
extensive  and  reaches  deepest,  even  involving  the  greatly  thickened 
serosa.  It  is  upon  this  arrangement  of  the  carcinomatous  tissue  that 
he  bases  his  argument  for  the  secondary  origin  of  the  ulcer,  his  reasoning 
being  as  follows : 

If  the  cancer  development  were  secondary,  one  would  expect  that 
it  had  taken  its  origin  from  some  one  point  in  the  mucous  membrane 
of  the  ulcer  margin.  One  could  then  easily  understand  the  develop- 
ment of  a  cancer  focus  located  beside  the  ulcer,  or  even  encroaching 
upon  it  to  some  extent.  But  it  would  be  impossible  to  understand  why 
just  the  deepest  part  of  the  ulcer,  far  removed  from  the  margins,  should 
be  most  strongly  infiltrated,  while  the  cancer  development  in  the  mar- 
gins should  only  reach  a  few  millimeters  outward.  The  cicatricial 
tissue  forming  the  floor  of  the  ulcer  would,  moreover,  offer  more  unfavor- 
able ground  for  the  infiltration  of  the  cancer  than  the  relatively  normal 
portions  of  the  stomach  wall  lying  adjacent  to  the  ulcer. 

This  arrangement  of  the  cancer  tissue  is  best  explained  on  the  ground 
that  the  centre  of  growth  was  in  the  mucous  membrane  originallj' 
present  over  the  centre  of  the  ulcer  itself,  and  that  from  there  the 
cancer,  following  Ribbert's  laws  of  growth,  extended  into  the  deepest 
parts  of  the  stomach  wall  beneath,  as  well  as  into  the  submucosa. 
The  mechanical  irritation,  softening  and  disintegration  of  the  mass 
of  cancer  tissue,  would  then  lead  to  the  production  of  an  ulcer,  with 
the  above-mentioned  arrangement  of  cancer  tissue. 

It  is  an  undisputed  fact  that  such  changes  do  occur  and  threaten 
the  life  of  a  certain  proportion  of  ulcer  patients.     Just  how  great  this 

1  Ziegler's  Beitrage,  September  12,  1912. 


156 


ACUTE  AND  CHRONIC   ULCER 


Fia.  28 


•..••"■-■^.■.:-"7i'-  -••••••■'-.•(^**t--:''    c>-'>'& 


— A 


ii^*^C 


^v^. 


_£ •■■■•-^■avivr.-y. ...•'>  ^  -  - .  •  - 


Carcinomatous  ulcer  of  stomach.  M,  mucosa  showing  ahnost  perpendicular  margin.  There  is 
considerable  round-cell  infiltration  at  E.  At  ^4,  the  mucosa  is  gradually  disappearing  to  be  replaced 
by  necrotic  tissue;  M,  M,  muscularis  mucosse;  S,  submucosa,  containing  much  connective  tissue 
and  strands  of  carcinoma  tissue;  X,  muscularis;  C,  large  mass  of  carcinoma  tissue;  Y,  carcinoma 
infiltrating  muscularis  in  every  direction.  This  drawing  shows  especially  the  large  amount  of  carci- 
noma in  the  base  of  the  ulcer,  with  infiltration  of  the  muscularis  and  marked  infiltration  along  the  line 
of  the  submucosa  as  described  by  Stromeyer. 


COMPLICATIONS  OF   ULCER  157 

proportion  is,  is  a  matter  of  some  dispute,  the  figures  ranging  from 
the  older  statistics  of  6  per  cent,  to  the  present  estimate  of  71  per 
cent,  of  Wilson  and  MacCiirty  writing  from  the  Mayo  clinic.  The 
writer  can  only  state  that  in  but  7  per  cent,  of  his  cancer  cases  was  it 
possible  to  obtain  a  previous  history  of  indigestion  that  might,  even 
with  leniency,  be  interpreted  as  due  to  previous  ulceration,  neither 
has  he  found  carcinoma  of  frequent  occurrence  in  those  whom  he 
has  treated  for  ulcer. 

Ulcus  carcinomatosum  may  be  suspected  in  a  case  of  supposed 
simple  ulcer  under  the  following  conditions: 

1.  When  lactic  acid  or  lactic  acid  bacilli  appear  in  the  gastric  con- 
tents. The  degree  of  hydrochloric  acidity  is  of  much  less  importance 
than  this.  Reductions  may  occur,  but,  as  a  rule,  hydrochloric  acidity 
remains  high  in  many  cases  even  throughout  the  course  of  the  disease. 
When  lactic  acid  appears  it  is  probable  that  the  patient  has  passed 
the  stage  in  which  operation  can  result  in  radical  cure. 

2.  Cases  of  uncomplicated  ulcer  that  do  not  improve  under  treat- 
ment, especially  if  blood  tests  of  the  stools  be  positive  during  the 
third  and  fourth  week  of  treatment,  are  to  be  regarded  with  suspicion. 

3.  General  failure  of  flesh  and  strength  following  an  ulcer  cure 
without  apparent  cause,  with  or  without  occult  bleeding,  justify 
exploration. 

4.  Sudden  failure  in  appetite  amounting  often  to  actual  aversion 
to  all  food,  that  cannot  be  explained  by  temporary  derangements  of 
digestion,  should  call  for  a  most  painstaking  clinical  study  of  the  case. 

There  is  nothing  in  the  physical  examination  of  the  patient  to  assist 
in  forming  a  correct  diagnosis.  The  only  hope  of  the  patient  when 
such  a  complication  occurs,  lies  in  a  radical  operation,  performed  so 
early  in  the  disease  that  a  diagnosis  of  malignant  degeneration  cannot 
be  definitely  made,  at  the  time  at  which  the  operation  is  advised.  In 
other  words,  certainty  of  diagnosis  means  that  it  is  too  late  to  hope 
for  radical  cure — and  that  to  give  the  patient  every  possible  chance, 
exploration  must  be  advised  and  urged  in  those  whose  symptoms  are 
merely  suspicious  of  early  malignancy.  Should  exploration  be  negative, 
no  great  harm  will  result;  should  it  be  justified,  a  life  may  be  saved 
that  otherwise  is  doomed  to  a  distressing  end. 

Perforation. — The  frequency  of  perforation  is  much  greater  in 
hospitals  as  the  symptoms  of  ulceration  are  often  ignored  by  ignorant 
patients  until  they  are  forced  to  enter  the  wards  with  hemorrhage  or 
perforation. 

Habershon^  places  the  frequency  at  18  per  cent.,  Gerhardt  at  13 

^  St.  Bartholomew's  Hospital  Reports,  1890. 


158  ACl'TE  AM)  CHRONIC   ULCER 

per  cent.,  and  Cantlie,  at  the  Royal  \'ict()ria  Hospital,  Montreal,  at 
10  per  cent.  Fenwiek  and  Deaver  consider  the  accident  somewhat 
less  frequent,  the  former  estimating  the  casualty  at  5.5  per  cent.,  the 
latter  at  4  per  cent.  In  the  writer's  series  of  all  hospital  and  private 
cases,  4  per  cent,  perforated,  the  complication  l)einij;  six  times  more 
frequent  in  the  hospital  series  than  in  the  i)rivate  cases.  Perforations 
are  less  common  with  ulcers  that  have  previously  hied,  because  of 
the  more  radical  and  efficient  treatment  that  naturally  follows  the 
hemorrhage. 

Perforation  may  occur  with  both  acute  and  chronic  ulcer,  but  is 
less  conmion  with  the  chronic  form,  owing  to  the  protective  thickening 
of  the  base  of  the  ulcer  and  the  adhesions  that  may  form  at  the  site  of 
the  lesion,  reinforcing  the  i)oint  of  weakness. 

Ulcers  of  the  anterior  wall  are  more  liable  to  perforate  than  are  those 
elsewhere  located.  Pariser  estimates  that  of  201)  ulcers,  190  will  be 
on  the  posterior  wall,  and  of  these  4  will  perforate,  whereas  of  the  10 
ulcers  on  the  anterior  wall,  perforation  would  occur  in  8.  Ashhurst  con- 
cludes that  S  per  cent,  of  ulcers  are  located  on  the  anterior  wall,  and 
this  S  per  cent,  furnishes  nearly  three-fourths  of  all  the  perforations. 

According  to  Fenwiek,  the  acute  gastric  ulcer  usually  perforates 
the  comi)aratively  thin  wall  of  the  stomach  in  the  cardiac  half  of  the 
viscus  on  the  anterior  wall  near  the  lesser  curNature,  whereas  the 
chronic  form  is  most  prone  to  perforate  in  the  pyloric  portion  of  the 
stomach  on  the  posterior  aspect  near  the  upper  margin.  Perforating 
ulcers  formerly  considered  gastric  are  now  generally  conceded  to  be  in 
most  cases  on  the  duodenal  side  of  the  ])ylorus. 

The  reason  for  the  greater  tendency  of  ulcers  of  the  anterior  wall 
to  perforate  lies  in  the  relation  of  the  stomach  to  surrounding  viscera. 
The  anterior  wall  lies  freely  exposed  to  the  general  peritoneal  cavity, 
and  is  subject  to  greater  degrees  of  contraction  and  dilatation.  It  is 
furthermore  subject  to  traumatism  acting  throughout  the  anterior 
abdominal  wall. 

The  posterior  surface  of  the  stomach  is  ])laccd  in  contact  with  the 
rigid  protective  spinal  column  within  the  confines  of  the  lesser  jieri- 
toneal  .sac,  and  is  in  close  relation  with  the  pancreas,  duodenum,  and 
liver.  Owing  to  these  relations,  ulcers  on  the  posterior  wall  are  more 
apt  to  contract  protecting  adhesions  and  arc  therefore  not  so  liable 
to  perforate. 

From  ulcer  of  the  anterior  wall  of  the  duodenum  fatal  perforation 
often  en.sues,  owing  to  the  absence  of  any  solid  viscus  that  can  act  as 
a  secondary  basis  for  the  ulcer,  but  when  ulceration  occurs  on  the 
posterior  wall,  perforation  is  often  prevented  by  the  pancreas  which  lie 
immediatcl\   behind  it.      ^Vcr<'  it  not  for  the  presence  of  the  i)ancreas 


rOMPIJCATIOSS  OF   ULCER 


159 


at  this  exact  p(jint  it  is  probable  that  a  much  greater  number  of  duodenal 
ulcers  would  perforate. 

Recurring  perforations  in  the  same  individual  are  not  uncommon; 
in  the  literature  of  the  year  instances  of  successive  operations  were 
reported  by  Cuff/  Willis,^  and  Schmitzler.'^ 

Perforation  may  be  acute,  subacute,  or  chnjnic. 


Fig,   20 


Perforated  gastric  ulcer.  The  stomach  is  adherent  to  the  pancreas  which  forms  the  base  of  the 
ulcer.  X,  ulcer;  P,  pancreas;  .S,  wall  of  stomach.  (From  the  Pathological  Mu-seum  of  the  Presby- 
terian Hospital,  New  York.) 


Acute  Perforation. — In  the  acute  form  the  perforation  is  unprotected 
by  adhesions,  so  that  the  gastric  or  duodenal  contents  escape  rapidly 
and  freely  into  the  peritoneal  cavity.  Following  perforation  of  a  gastric 
ulcer,  an  acute  diffuse  peritonitis  is  at  once  set  up,  the  infection 
spreading  rapidly  to  all  parts  of  the  abdominal  cavity.  The  contents 
of  the  duodenum,  on  the  other  hand,  are  relatively  sterile,  which 
accounts  for  the  fact  that  while  the  number  of  the  duodenal  perfora- 
tions is  large,  the  death  rate  is  comparatively  low.  Not  only  is  the 
duodenum  more  often  empty  at  the  time  of  the  perforation  than  is 
the  stomach,  but  a  protective  spasm  of  the  pylorus  is  induced  at  the 
time  of  the  accident,  preventing  further  ingress  of  chyme,  so  that  in 
duodenal  perforations  the  leakage  is  apt  to  be  limited. 

Owing  to  the  anatomical  situation  of  the  duodenum,  deeply  placed 
between  the  right  lobe  of  the  liver  and  the  gall-bladder,  the  contents 
do  not,  as  a  rule,  escape  into  the  peritoneal  cavity  as  is  the  case  with 
perforation  of  a  gastric  ulcer,  but  tend  to  travel  along  the  posterior 
aspect  of  the  hepatic  colon,  gravitating  downward  in  front  of  the  right 
kidney  and  eventually  into  the  right  iliac  fossa,  simulating  renal  or 


'  Briti.sh  Medical  Journal,  1907,  i,  25.5. 

■'  Report  to  Vienna  Medical  Society,  December,  1907 


-  Ibid.,  i.  926. 


100 


ACUTE  AND  CHRONIC   ULCER 


appendicular  abscess.  This  line  of  infection  may  occur  in  the  acute 
form  of  perforation,  althoujjh  it  is  especially  apt  to  be  the  case  with 
perforations  that  are  subacute. 


Fig.  30 


Perforated  gastric  ulcer.     P.  perforation;  M,  mu.si  uLui.^,  luiinujg  wluu  n mains  as  floor  of  the  ulcer; 
B,  border  of  ulcer.     (From  the  Pathological  Museum  of  the  Mt.  Sinai  Hospital,   New  York.) 


Fig.  31 


ItMIIIIIIIIII  III  I  I  lltl  M  jltlllln  I  11  M  III  I  II  III  III 

•  L-M       )  7  .V  *  5I 

INCHES  ;  J 

III.  I.  I.  I.  I.  I.  I.I  I  III  I  I.  I.I.  I.  I  I 


Perforated  duodenal  ulcer  in  an  infant  four  months  old.  .S,  stomach;  I),  duodenum;  P,  pyloric 
ring;  A,  perforated  ulcer  with  hemorrhagic  border.  (From  the  Pathological  Museum,  Presbyterian 
Hospital  New  York.) 


COMPLICATION,'^  OF  CLCEfi  161 

Syuiptuins. — In  man.y  of  the  cases  perforation  is  the  first  indication 
of  serious  gastric  trouble,  occurring  as  an  initial  symptom  in  3.4  per 
cent,  of  Fenwick's  acute  ulcers,  and  in  5  per  cent,  of  the  writer's. 
These  seem  to  be  low  figures  when  we  realize  how  many  acute  perfor- 
ations are  brought  to  the  hospital  oblivious  of  all  symptoms  of 
previous  ulceration. 

Hartley,  in  a  verbal  communication  to  the  writer,  states  that  in  his 
last  10  cases  of  perforation,  8  claimed  to  be  free  from  pain  or  indigestion 
before  the  accident.  In  8  of  13  cases  of  perforation  reported  by 
Andrews  a  history  of  previous  pain  was  denied.  Many  of  the  patients 
are,  however,  either  too  ill  or  too  stupid  to  remember  or  try  to  describe 
their  symptoms  preceding  the  perforation,  but  a  careful  history  taken 
after  their  recovery  will  usually  elicit  the  fact  that  they  suffered  from 
more  or  less  epigastric  pain  before  the  occurrence  of  the  accident. 

Ulcers  on  the  anterior  wall  are  so  often  unaccompanied  by  charac- 
teristic symptoms  that  the  ulcer  is  frequently  unrecognized  until  the 
event  of  perforation.  In  other  cases  perforation  is  preceded  by  signs 
of  active  ulceration.  Increase  in  the  intensity  of  pain,  together  with 
an  increase  in  its  constancy,  and  a  localized  feeling  of  "soreness"  in 
the  upper  right  quadrant  of  the  abdomen,  made  worse  on  exercise, 
should  occasion  apprehension  of  impending  disaster,  if  these  symptoms 
occur  in  a  patient  who  is  known  to  have  duodenal  ulcer. 

In  duodenal  perforation  it  is  usually  the  chronic  form  that  perfor- 
ates, which,  with  but  few  exceptions,  has  given  sustained  evidence  of 
its  presence,  together  with  a  distinct  exacerbation  of  its  symptoms 
for  some  days  or  weeks  prior  to  its  rupture. 

The  accident  may  occur  at  any  time,  even  during  the  hours  of  sleep; 
in  other  cases  it  may  follow  the  distention  of  the  stomach  by  food, 
dietetic  indiscretions,  straining  efforts  of  the  abdominal  muscles  or 
external  traumatism  acting  throughout  the  anterior  abdominal  wall. 
It  has  unfortunately  followed  the  indiscreet  use  of  a  stomach-tube 
and  attempts  to  empty  the  stomach  by  emetics. 

The  symptoms  of  acute  perforation  appear  simultaneously  with  the 
rupture.  The  patient  will  suddenly  be  seized  with  a  pain  that  is  diffi- 
cult to  describe  except  in  terms  of  severit}^  It  is  sharp  and  agonizing, 
and  even  speaking  produces  additional  suffering.  The  pain  is  at  first 
referred  to  the  upper  part  of  the  abdomen,  more  usually  in  the 
epigastric  or  the  right  hypochondriac  region,  or  it  may  be  umbilical. 
There  may  be  the  feeling  that  something  has  torn  or  burst  within  the 
abdomen. 

Vomiting  closely  follows  the  pain  in  about  one-half  the  cases,  the 
vomited  matters  being  frequently  blood-tinged,  but  repeated  vomiting 
does  not  seem  to  occur — an  important  point  in  the  differential 
U 


162  ACUTE  AND  CHRONIC   ULCER 

diagnosis  between  ulcer  and  acute  intestinal  obstruction  or  strangulation 
of  the  bowel,  in  which  repeated  efforts  of  vomiting  are  made.  In  other 
cases  vomiting  is  absent,  owing  to  inhibition  of  the  emetic  centres 
by  the  shock. 

Symptoms  of  collapse  speedily  supervene  if  general  peritoneal 
sepsis  results,  and  are  most  marked  in  the  perforation  of  gastric  ulcer. 
In  duodenal  perforation  the  shock  may  be  quite  insignificant  at  the 
onset,  may  not  appear  for  some  hours,  or  may  be  altogether  absent. 
The  absence  of  definite  symptoms  of  shock  should  therefore  never 
deter  us  from  early  exploration  when  perforation  is  suspected.  Syncope 
may  precede  the  accident  shock.  Fenwick  and  Crisp  report  cases  in 
which  syncope  followed  by  shock  were  the  only  symptoms  present. 

The  pulse  may  be  rapid  and  feeble,  as  is  usual  in  shock,  but  iri  many 
cases  the  jmlse  is  slow,  regular,  and  of  good  force.  This  is  especially  the 
case  with  duodenal  perforation.  iNIany  operations  have  been  delayed 
too  long  owing  to  the  general  excellence  of  the  pulse,  although  it  is 
clear  that  perforation  has  occurred. 

The  breathing  is  generally  shallow  and  thoracic,  the  movements  of 
the  abdomen  in  respiration  are  usually  restricted,  especially  on  the 
right  side. 

The  temperature  at  first  may  be  slightly  subnormal,  subsequently 
rising  a  little,  attaining  the  height  of  101°  or  even  more.  The  chief 
characteristic  of  the  temperature  is  its  slight  elevation  compared  with 
the  serious  condition  of  the  patient. 

Leukocytosis  is  usually  well-marked,  counts  of  12,000  to  30,000 
within  a  few  hours  of  the  accident  not  being  uncommon.  The  poly- 
morphonuclears are  regularly  increased.  In  cases  of  overwhelming 
infection  the  total  number  of  leukocytes  may  not  be  increased, 
although  there  is  always  a  relative  increase  in  the  percentages  of 
the  polymorphonuclears. 

The  most  constant  sign  of  perforative  peritonitis  is  rigidity.  The 
abdominal  wall  assumes  a  board-like  rigidity  that  is  most  character- 
istic. Moynihan  writes:  "No  other  condition  than  perforation  of  the 
stomach  or  duodenum  can  give  rise  to  such  unalterable  and  unyielding 
tension  of  the  muscles."  It  never  for  one  instant  slackens  until 
death  is  imminent.  The  maximum  point  of  rigidity  is  usually  near 
the  site  of  the  perforation,  and  for  this  reason  early  and  careful  exami- 
nation should  be  made  to  determine  the  probable  site  of  rupture.  It 
is  usually  found  over  the  upper  part  of  the  right  rectus  muscle.  In 
duodenal  perforation  initial  rigidity  may  l)e  slight,  occasionally  barely 
to  l)e  detected,  or  there  may  be  an  initial  rigidity  which  after  a  short 
time  grows  less  .so  that  one  may  be  deceived  by  a  period  of  apparent 
improvement.     Sooner  or  later  the   rigidit\"   reapj^ears   and   becomes 


COM  P  Lie  AT  If)  XH  OF  ULCEIi,  163 

progressive.  In  almost  every  instance  of  duodenal  perforation  the 
right  side  is  not  only  more  rigid  but  more  tender  than  the  left,  but 
the  right  iliac  fossa  may  l^e  the  most  exquisite  tender  area  of  all.  In 
49  cases  of  ruptured  duodenal  ulcer  reported  by  Moynihan  in  no  fewer 
than  19  had  the  diagnosis  of  appendicitis  been  made.  In  rare  cases 
with  overwhelming  infection  death  may  occur  from  peritoneal  sepsis, 
without  any  attempt  at  repair  by  plastic  exudation.  In  these  cases 
rigidity  may  never  occur. 

Tenderness  at  first  corresponds  to  the  area  of  greatest  pain,  later, 
when  peritonitis  develops,  the  tenderness  becomes  more  general. 
This  persists  after  peritonitis  with  its  consequent  tympany  has  rendered 
the  detection  of  rigidity  difficult.  There  is  a  remarkable  correspon- 
dence between  the  seat  of  maximum  tenderness  and  the  point  of 
perforation  which  is  of  importance  in  determining  the  selective  point 
for  operation. 

Attention  has  been  called  to  the  frequent  absence  of  liver  dulness, 
occasioned  by  the  presence  of  air  or  gas  in  the  abdominal  cavity,  as  a 
sign  of  perforation.  This  sign  is  now  recognized  as  variable,  and  not 
distinctive.  Tympany  without  perforation  may  produce  similar 
physical  signs.  It  should  never  be  relied  upon  to  determine  the  question 
of  operation. 

In  13  of  Andrews'  cases  liver  dulness  was  absent  in  3,  diminished  in 
7,  and  normal  in  3. 

Of  43  perforation  cases  compiled  by  English,  liver  dulness  was 
absent  in  12,  diminished  in  20,  normal  in  11. 

The  fatality  varies.  In  the  modern  statistics  the  mortality  is  much 
less  than  in  those  compiled  a  few  years  ago,  not  only  because  the 
importance  of  early  operation  is  now  universally  recognized,  but  also 
an  increasing  number  of  ''appendicitis"  cases  are  being  sent  to  the 
hospitals  for  operation,  and  many  of  these  turn  out  to  be  perforations. 
Martens,^  with  a  large  experience  in  operating  upon  gastric  perforations, 
reports  that  almost  without  exception  his  cases  were  admitted  to  the 
hospital  with  the  diagnosis  of  appendicitis.  This  is  especially  apt  to 
be  the  case  in  the  perforations  of  duodenal  ulcer.  According  to  Deaver, 
perforation  constitutes  80  per  cent,  of  the  deaths  from  ulcer. 

Subacute  Perforation. — Perforation  is  said  to  be  subacute  in  those 
cases  in  which  the  extravasation  is  so  slight  that  the  resulting  peri- 
tonitis is  localized. 

Extravasation  may  be  limited  from  a  variety  of  causes: 

1.  Whenever  ulceration  is  gradual  so  that  perigastritis  occurs,  the 
point  of  perforation  may  be  protected  by  adhesions,  so  that  escape  of 

1  Deutsch.  med.  Woch.,  1907,  p.  1851. 


164  ACUTE  AND  CHRONIC   ULCER 

gastric  or   duodenal   contents   into   the   general   peritoneal   cavity   is 
prevented. 

2.  The  perforation  may  occur  at  a  time  when  the  viscus  is  empty. 
This  fortunate  circumstance  is  more  common  in  duodenal  than  in 
gastric  ulcer,  for  obvious  reasons.  In  rupture  of  duodenal  ulcer  the 
protective  closure  of  the  pylorus  preventing  escape  of  contents  of 
stomach  into  the  ruptured  portion,  has  previously  been  alluded  to. 

3.  The  rent  may  be  more  or  less  completely  closed  by  an  exudation 
of  plastic  lymph  thrown  out  just  before  the  time  of  actual  rupture,  or 
else,  in  rare  instances,  the  omentum  may  be  found  plugging  up  the 
false  opening. 

^Yhen  local  peritonitis  occurs  in  subacute  perforation  there  is  formed 
an  abscess  cavity  communicating  with  the  stomach  or  duodenum  and 
shut  off  by  adhesions  from  the  general  peritoneal  sac.  Such  an  abscess 
may  remain  for  a  considerable  period  of  time  without  marked  change, 
draining  through  the  point  of  rupture,  or  else  it  may  extend,  the  rule 
being  that  extension  occurs  more  readily  in  the  direction  of  that  part 
of  the  wall  that  is  formed  by  adhesions.  In  many  cases  this  advancing 
infection  leads  to  a  progressive  fibrinopurulent  peritonitis.  In  other 
cases  the  abscess  may  invade  the  structure  of  the  liver,  more  rarely 
the  substances  of  the  pancreas,  or  there  may  be  formed  fistulous 
openings  into  hollow  viscera,  or  through  the  anterior  abdominal  wall. 
Perforation  of  aorta,  portal  vein,  and  superior  mesenteric  vein  has 
occurred.  Gastrocolic  fistula  is,  however,  less  common  in  ulcer  than 
in  cancer.  Many  interesting  cases  are  described  showing  to  what  a 
remarkable  extent  burrowing  of  the  pus  has  occurred.  A  case  has 
been  reported  of  the  burrowing  of  the  abscess  along  the  greater  vessels 
of  the  neck  when  it  pointed  and  discharged.  In  one  case  the  pus  was 
discharged  at  the  angle  of  the  right  scapula.  It  is  clear  that  an  abscess 
which  forms  as  the  result  of  subacute  perforation  may  burrow  in  any 
direction,  and  may  reach  the  body  in  any  region  by  almost  any  route, 
however  devious  it  may  appear. 

The  most  common  form  of  abscess  in  this  form  of  perforation  is  the 
type  commonly  spoken  of  as  subj)hrenic  abscess.  Abscesses  caused 
by  rupture  of  anterior  ulcers  or  of  ulcers  near  the  lesser  curvature, 
usually  form  under  the  left  lobe  of  the  liver,  being  bounded  by  the 
stomach  below,  and  posteriorly  l)y  the  gastric  hepatic  omentum.  If 
rupture  occurs  of  an  ulcer  near  the  fundus  the  left  })oundary  may  be 
formed  by  the  spleen. 

Perforation  of  ulcers  on  the  posterior  wall  usually  cause  an  infection 
of  the  lesser  j)eritonea]  cavity  (an  "ein])yema  of  the  bursa  omentalis"). 
The  purulent  process  fret|uently  invades  the  substance  of  the  liver,  or 
the  pus  may  l)nrrow  in  front  of  the  anterior  margin  of  the  left  lobe 


COMPLICATIONS  OF   ULCER  165 

of  the  liver,  so  as  to  be  subdiaphragmatic  in  type.  Infection  of  the 
pleura  is  common  in  these  cases,  usually  resulting  in  empyema.  Per- 
foration into  the  i)leura,  lung,  or  pericardium  may  occur.  Pneumonia 
is  not  uncommon. 

Symptoms. — The  symptoms  of  subacute  perforation  differ  from 
those  of  the  acute  form  chiefly  in  their  degree  of  intensity.  An  increase 
of  ulcer  symptoms  is  usually  noted  preceding  the  perforation — pain 
more  intense,  more  constant,  and  more  readily  increased  by  exertion. 
The  feeling  of  local  soreness  and  an  increased  tenderness  are  suspicious 
signs  of  impending  disaster,  and  in  an  ulcer  patient  should  always 
excite  apprehension. 

The  initial  pain  is  severe,  often  excessively  so,  but  it  lacks  the  agoni- 
zing quality  seen  in  the  acute  cases.  The  pain  may  lessen  considerably 
in  a  few  hours,  often  deceiving  us  as  to  the  gravity  of  the  attack. 
The  pain  is  usually  more  accurately  localized  than  in  the  acute  cases. 

Shock  is  less  frequent  than  in  the  acute  form,  amounting  in  the 
majority  of  cases  merely  to  a  sense  of  extreme  prostration  and  a  reali- 
zation of  serious  illness.  Vomiting  is  somewhat  more  common.  The 
appearance  of  the  patient  may  be  quite  normal.  The  abdomen  may 
be  everywhere  tender,  but  the  point  of  maximum  tenderness  is  usually 
quite  distinct.  Rigidity  is  regularly  present,  but  more  localized  and 
less  general  than  in  the  acute  types.  Moynihan  describes  the  painful 
and  tender  area  feeling  ''as  if  a  flat,  hard  disk  had  been  inserted  into 
the  abdominal  wall."  The  symptoms  change  slowly.  The  tenderness 
may  become  more  localized,  or  may  spread,  if  progredient  peritonitis 
result.  Subsequent  symptoms  are  those  of  sepsis,  common  to  all 
suppurative  foci. 

Chronic  Perforation. — A  perforation  may  be  said  to  be  chronic  when 
by  reason  of  perigastric  adhesions  no  further  infection  of  peritoneum 
either  local  or  general  ensues.  In  the  majority  of  these  instances  the 
base  of  the  ulcer  has  become  adherent  to  some  of  the  neighboring 
organs,  so  that  by  an  extension  of  the  ulcerative  process,  the  base  of 
the  ulcer  is  formed  by  pancreatic  or  hepatic  tissue,  or  else  by  dense 
fibrinous  material.  Many  patients  go  on  for  years  with  an  ulcer  whose 
base  is  formed  by  one  of  the  above-mentioned  structures.  In  other 
cases  extension  into  these  adherent  structures  may  occur,  causing 
abscess  cavities  and  fistulous  tracts.  The  time  at  which  the  actual 
penetration  of  the  true  ulcer  base  occurs  is  not  apt  to  be  marked  by 
characteristic  symptoms.  Pain  more  or  less  constant  and  influenced 
unfavorably  by  exertion  and  by  the  dragging  of  the  stomach  by  the 
mechanical  weight  of  food,  are  the  chief  symptoms.  Pus  is  present  in 
the  fasting  stomach  of  these  patients,  and  is  of  the  utmost  importance 
in  diagnosis.     The  stomach  contents  are  not,  however,  foul,  as  is  so 


166  ACUTE  AND  CHRONIC   ULCER 

frtxiueiitly  the  case  of  pro^Tessive  ulceration  of  iiei^hl)orin,u'  orjians  in 
cancer. 

Tenderness  is  i)ersistent  and  localized.  Local  rigidity  is  usually, 
but  not  invariably  present.  Symptoms  of  sepsis  induced  by  slow 
absorption,  progressive  emaciation,  fever  of  an  intermittent  type, 
often  accom])anied  by  chills  and  sweating,  are  liable  to  supervene. 

Differential  Diagnosis  of  Perforation. — In  the  majority  of  instances 
the  occurrence  of  perforation  may  be  readily  diagnosticated,  although 
it  may  be  difficult,  in  the  absence  of  previous  history,  to  determine 
the  site  of  perforation.  The  sudden  onset,  tendency  to  collapse,  and, 
most  important,  the  presence  of  unyielding,  unchanging  rigidity,  make 
it  evident  that  an  acute  surgical  abdomen  exists.  In  the  majority  of 
hospital  patients  a  finer  diagnosis  than  this  is  not  of  much  value,  nor 
is  it  im])ortant  to  differentiate  between  gastric  and  duodenal  perfora- 
tions. The  main  thing  is  to  decide  that  a  perforation  has  taken  place, 
and  to  operate  without  further  delay.  The  seat  of  maximum  tenderness 
and  the  initial  area  of  rigidity  or  the  area  of  greatest  rigidity  are 
sufficient  to  determine  the  seat  of  incision. 

^Mistakes,  however,  have  been  frequently  made,  even  l)y  the  most 
careful  and  experienced  surgeons.  The  abdomen  has  been  frequently 
opened  for  perforation,  and  no  perforation  found. 

Manges  reports  the  case  of  a  woman,  aged  twenty-seven  years,  with 
the  clinical  history  of  gastric  ulcer,  who  suddenly  was  seized  by  intense 
pain  and  tenderness  in  epigastrium  with  marked  rigidity.  Operation 
was  performed,  but  no  perforation  and  no  peritonitis  found— merely 
an  uncomplicated  gastric  ulcer. 

Diagnosis  from  Pleurisy  and  Acute  Lobar  Pneu)nonia. — Pleurisy, 
e.specially  diaphragmatic,  and  acute  lobar  pneumonia  may  be  accom- 
pained  at  the  onset  by  acute  se\cre  pain  in  the  abdomen  and  abdominal 
rigidity,  so  closely  simulating  perforation  as  to  deceive  even  the  most 
expert  surgeons. 

In  the  pulmonary  cases,  however,  the  temperature  is  usually  high, 
ranging  between  10.'^°  and  10.")°,  whereas  in  perforation  the  temperature 
exceeds  the  height  of  102°  only  in  rare  instances.  In  the  cases  of  pul- 
monary origin  the  resj)irations  are  frequent,  usually  30  to  40,  which, 
accompanied  at  the  onset  by  a  ])ulse  not  usually  over  100,  is  quite 
different  from  the  rapid  pulse  and  but  slightly  accelerated  respiration 
rate  of  perforation.  In  the  pulmonary  cases  abdominal  rigidity  is 
neither  as  well-marked  nor  as  unchanging  as  in  perforation — it  is  not 
nnconimon  to  n(»tice  dillcrences  in  its  intensity  at  ditterent  times  during 
the  physical  examination.  Ksi)ecially  apt  is  the  rigidity  to  yield  for 
an  instant,  at  the  end  of  expiration.  This  does  not  occur  with 
ulcer. 


COMPLICATIONS  OF   ULCER  167 

Diagnosis  from  Erythematous  Diseases. — In  the  various  gastro- 
intestinal crises  of  the  erythema  group  of  skin  diseases  we  may  have  a 
symptom-complex  somewhat  misleading,  but  we  are  aided  in  our 
diagnosis  by  the  history  of  previous  attacks,  by  the  spasmodic  colicky 
character  of  the  pain,  and  by  the  evidences  of  erythema,  purpura, 
angioneurotic  edema  or  urticaria  of  the  skin.  Nevertheless  the  abdomen 
has  been  opened  under  an  erroneous  diagnosis  in  these  cases. 

Diagnosis  from  Ajjpemlicitis. — The  disease  most  frequently  mistaken 
for  perforation  is  appendicitis.  The  frequency  in  which  perforated 
ulcers,  especially  of  the  duodenum,  enter  the  hospitals  with  the  diag- 
nosis of  appendicitis,  has  already  been  attended  to. 

In  some  cases  a  differential  diagnosis  is  a  matter  of  extreme  difficulty, 
although  the  consequences  are  not  serious  as  long  as  the  condition  of 
acute  surgical  abdomen  is  recognized,  although  in  the  majority  of 
cases  the  diagnosis  may  be  made.  The  various  points  for  diagnosis 
are  shown  in  the  accompanying  table. 

Differential  Diagnosis  between  Perforation  of  Ulcer  and  Appendicitis 

Perforated  Ulcer  Perforated  Appendix 

Pain  sudden  and  overwhelming.  Pain  more  gradual  and  more  colicky. 

Pain  referred  to  upper  abdomen,  Pain  general  at  first,  becoming  grad- 

gradually  becoming  general.  ually  more  localized. 

Collapse  marked.  Collapse  usually  slight. 

Rigidity  general,  intense.  Rigidity  locahzed,  less  unyielding. 

Diagnosis  from  Acute  Hemorrhagic  Pancreatitis.— Acute  hemorrhagic 
pancreatitis  may  resemble  perforation  in  the  severity  of  the  initial 
pain  and  consequent  shock. 

The  previous  history,  if  any  is  obtained,  is  more  often  that  of  gall- 
stones— inaugural  symptoms  of  ulcer  are  not  obtained.  The  pulse  is 
bad  from  the  start  and  disproportionate  to  all  other  vital  signs.  The 
face  is  usually  slightly  cyanosed.  Vomiting  is  a  more  conspicuous 
feature.  Tenderness  is  most  marked  in  the  median  line  over  the 
inflamed  gland — not  more  intense  on  the  right  side  as  is  the  case  in 
the  majority  of  perforations.  A  painful,  tender,  tumor  mass  may 
even  be  felt,  not  moving  with  respiration,  and  lying  transversely  just 
above  the  navel.  Rigidity  is  usually  less  marked  and  less  general  in 
pancreatitis  than  in  perforation. 

Despite  these  points  of  difference,  a  differential  diagnosis  between  the 
two  conditions  may  be  impossible,  especially  when  posterior  perfora- 
tions have  involved  the  lesser  peritoneal  cavity  forming  an  empyema 
of  that  sac. 

Diagnosis  from  Acute  Intestinal  Obstruction. — ^Acute  intestinal 
obstruction  is  marked  by  the  onset  of  acute,  severe  pain  and  by  ab- 


168 


ACUTE  AND  CHRONIC   ULCER 


dominal  rigidity.  The  pain,  however,  is  more  wave-Hke  and  colicky 
in  character — initial  collapse  is  usually  wanting.  Rigidity  is  not  as 
marked  as  in  perforation,  and  often  is  delayed  until  the  occurrence  of 
peritonitis  which  regularly  appears  late  in  these  cases.  The  temper- 
ature is  not  elevated  until  the  appearance  of  peritonitis.  The  most 
marked  symptom  of  obstruction  is  vomiting — not  only  of  ingested 
food,  but  of  intestinal  contents  approaching  the  stercoraceous  in 
type.  Vomiting,  on  the  other  hand,  occurs  only  in  about  one-half  of 
the  cases  of  perforation,  and  the  vomiting  act  is  not  apt  to  be  repeated. 

Rupture  of  the  Gall-bladder.— Rupture  of  the  gall-bladder  seldom 
occurs  with  the  suddemiess  of  perforation.  There  are  usually  marked 
local  symptoms  of  severe  gall-bladder  infection  preceding  the  rupture, 
although  cases  have  been  reported  in  which  a  diflferential  diagnosis 
before  the  operation  has  been  impossible. 

Perigastritis  and  Adhesions. — Ulcers  which  encroach  upon  the  peri- 
toneal coat  of  the  stomach  are  regularly  accompanied  by  local  thick- 
ening of  the  peritoneum  at  the  site  of  their  base.  This  is  a  conservative 
process,  as  it  reinforces  the  weakened  area  and  prevents  perforation. 
In  many  cases  the  stomach  becomes  adherent  at  this  point  to  any  one 
of  the  neighboring  organs.  These  adhesions  differ  in  no  respect  from 
those  encountered  in  other  parts  of  the  peritoneal  cavity,  although 
owing  to  the  chronicity  of  the  ulcer  they  are  more  apt  to  be  dense  and 
resistant.  Occasionally  there  occurs  a  deposition  of  lime  salts  in  these 
adhesions  sufficient  to  turn  the  edge  of  a  knife. 

Adhesions  with  neighboring  parts  are  contracted  with  less  frequency 
than  was  at  one  time  supposed.  Jaksch  found  adhesions  in  40  per 
cent,  of  his  cases,  Lebert  in  42  per  cent.,  while  in  Fenwick's  cases  of 
chronic  ulceration  they  were  present  in  46  per  cent.  On  the  other 
hand,  Fenwick  found  adhesions  in  6  per  cent,  of  his  acute  cases.  To 
show  the  relative  frequency  with  which  the  various  neighboring  organs 
become  adherent  to  the  bases  of  the  ulcer,  Fenwick  gives  the  following 
table,  compiled  from  an  analysis  of  123  cases: 


Number  of  cases 

Organ. 

adherent. 

Per  cent. 

Pancrea.s  alone        ... 

....     49 

40.0  \ 

Liver  alone 

...     30 

25.8       74.9 

Pancreas  and  liver 

.      10 

8.1  . 

Colon 

....       7 

5.7 

Liver  and  colon       ... 

.      .      .      .       4 

3.2 

Spleen 

.      .      .      .       2 

1.6 

•    25.1 

Mesentery 

3 

2.4 

Three  or  more  organs  . 

.      15 

12.2 

100.0 

100.0 

COMPLICATIONS  OF  ULCER  169 

The  ulcer  thus  contracts  adhesions  with  the  Hver  and  pancreas  in  three- 
fourths  of  all  the  cases  in  which  adhesions  are  present. 

Although  a  local  perigastritis  is  nature's  method  of  putting  a  patch 
upon  the  weakened  point,  the  presence  of  adhesions  is  not  without 
certain  deleterious  results.  The  fixation  of  the  movable  stomach 
upon  an  immovable  organ  such  as  the  liver  or  pancreas  naturally  tends 
to  hamper  the  muscular  movements  of  the  stomach  wall,  and  to  lead 
to  more  or  less  muscular  insufficiency.  Furthermore,  such  a  fixation 
may  seriously  interfere  with  the  proper  contraction  of  the  ulcer  that 
is  necessary  for  its  repair.  Again,  many  deaths  occur  from  hemorrhage 
the  result  of  adhesions  to  and  erosions  into  the  neighboring  parts;  the 
bloodvessels  of  the  pancreas  and  liver  have  frequently  been  opened  and 
erosions  into  almost  all  of  the  neighboring  bloodvessels  has  occurred. 

In  the  majority  of  instances,  perigastric  adhesions  give  no  additional 
symptoms  to  those  of  the  ulcer  itself.  In  other  cases  the  adhesions 
are  responsible  for  man}-  obscure  symptoms  which  develop  after  the 
cure  of  chronic  ulcer,  although  they  seldom  seem  to  interfere  with  the 
processes  of  digestion,  or  to  shorten  life.  These  symptoms  may  be  of 
neuralgic  character  occurring  from  time  to  time  without  any  direct 
relation  to  the  taking  of  food,  or  they  may  appear  after  eating,  usually 
within  a  very  short  time  after  the  meal,  as  a  result  of  the  mechanical 
interference  with  the  movements  of  the  stomach,  and  are  propor- 
tionate to  the  quantity  rather  than  to  the  quality  of  the  food.  In 
other  cases  they  occasion  only  a  sense  of  vague  uneasiness  more  or 
less  constant,  or  an  annoying  sensation  described  by  the  sufferers  as 
a  "dragging"  pain.  It  is  very  characteristic  of  all  localized  inflam- 
mation of  serous  membranes  that  adhesions  give  rise  to  a  pain  which 
is  increased  by  exertion  and  by  an  erect  posture.  The  patients  say 
that  their  pain  diminishes  during  the  night  and  gradually  increases  ^ 
during  the  day,  to  arrive  at  its  maximum  during  the  early  evening, 
and  that  they  obtain  relief  from  their  pain  only  by  lying  down.  The 
increase  in  these  pains  by  the  mechanical  weight  of  food  is  indicative 
of  a  gastric  origin. 

During  the  acute  exacerbation  of  perigastric  inflammation,  the  pain 
becomes  more  or  less  constant  and  is  influenced  to  a  greater  extent 
by  exertion,  by  change  in  posture,  and  by  the  mechanical  dragging 
whenever  food  or  drink  is  taken.  The  increase  in  local  tenderness, 
and  usually  a  localized  rigidity,  accompany  these  exacerbations. 

Pain  in  the  region  of  the  shoulder  is  commonly  observed  when  there 
are  adhesions  binding  the  stomach  to  the  liver.  Steady  boring  pains 
in  the  back  occurring  in  attacks  of  great  severity  are  suggestive  of 
adhesions  to  the  pancreas,  with  or  without  chronic  perforation  and 
erosion  of  its  substance.     In  the  latter  instance  pus  cells  are  often 


170  ACUTE  AND  CHRONIC   ULCER 

fmiiul  in  the  gastric  contents.  Pain  rumiing  around  the  chest  and 
causing  a  feeling  of  constriction  in  the  lower  thorax  is  observed  in 
ulcers  of  the  lesser  curvature  with  adhesions  to  the  liver  or  diaphragm 
especially  if  these  ulcers  are  near  the  cardiac  end  of  the  stomach. 
Duodenal  ulcers  frequently  contract  adhesions  with  the  gall-bladder. 

In  ulcers  of  the  first  portion  or  at  the  junction  of  the  first  and  second 
portions  of  the  duodenum,  on  its  upper  posterior  wall,  the  common  bile 
duct  may  be  caught  by  adhesions  as  it  passes  behind  the  duodenum, 
and  compressed.  A  number  of  such  cases  have  been  recorded.  Portal 
obstruction  or  portal  thrombosis  from  compression  has  occurred  as 
a  result  of  deep  cicatrization  of  a  chronic  duodenal  ulcer. 

Progressive  Perigastritis. — It  may  happen  that  the  perigastritis 
instead  of  remaining  localized  to  the  site  of  the  ulcer,  may  spread 
so  as  to  involve  a  greater  part  of  the  surface  of  the  stomach.  This 
form  of  inflammation  is  very  chronic  in  its  type,  leads  to  a  very  marked 
thickening  of  the  peritoneal  coat  of  the  stomach,  and  even  extends  to 
involve  the  peritoneal  folds  which  connect  the  stomach  with  the 
neighboring  parts.  In  some  instances  the  stomach  is  so  firmly  welded 
to  all  the  structures  about  it  that  its  dissection  is  impossible.  The 
result  is  that  the  peristaltic  movements  of  the  stomach  are  greatly 
impaired.  By  contraction  of  the  fibrous  thickening  of  its  wall  the 
stomach  may  become  compressed  and  distorted,  being  occasionally 
reduced  to  the  size  and  shape  of  a  section  of  the  bowel.  Fibrous  cords 
may  form,  pass  across  the  anterior  surface  of  the  stomach,  usually 
between  the  liver  and  the  great  omentum,  which  may  divide  the 
stomach  into  two  unequal  pouches,  practically  forming  the  hour-glass 
stomach.  In  some  cases  there  results  a  line  of  ulceration  in  the  mucous 
membrane  along  the  line  of  compression.  Volvulus  may  occur  in 
these  cases. 

Hymptovis. — The  symj)toms  of  this  form  of  perigastritis  are  some- 
what indefinite  in  character,  many  cases  running  their  course  without 
any  symptoms  whatever.  In  other  cases  there  is  a  marked  intoler- 
ance of  the  stomach  for  any  ordinary  quantity  of  food,  and  the  stomach 
will  reject  its  contents  if  more  than  a  small,  definite  amount  be  taken. 
Ordinarily  there  is  pain,  more  or  less  constant,  in  the  upper  abdomen," 
with  tenderness  which  often  passes  beyond  the  normal  stomach  boun- 
daries. This  extension  of  the  tenderness  is  due  to  the  involvement  of 
the  great  or  lesser  omentum.  Vomiting  and  exacerbation  are  attendant 
.symptoms.  Edema  and  ascites  may  occur  from  compression  of  the 
portal  vein.  Slightly  irregular  temperature  is  noted  in  a  majority  of 
cases. 

Cicatricial  Contractions.  Pyloric  stenosis  is  the  connnonest  sequela 
of  gastric  ulcer.    In  almost  all  ulcers  at  or  near  the  pylorus  there  occurs 


COMPLICATIONS  OF   ULCER  171 

a  slifi'ht  impairment  of  the  pyloric  opening,  which  gives  rise  to  the 
hyperaci(lit,y  and  hypersecretion  to  which  reference  has  j)reviousIy 
been  made.  Temporary  pyloric  spasm  characterized  by  attacks  of 
acute  hypersecretion  is  common  during  the  course  of  both  acute  and 
chronic  ulcer.  These  two  forms  of  pyloric  contraction  are  very  slight 
and  often  of  but  short  duration,  and  it  is  not  customary  to  speak  of 
either  one  as  pyloric  stenosis.  This  term  should  be  reserved  for  those 
cases  in  which  cicatricial  contraction  has  occurred  at  the  site  of  the 
ulcer,  causing  a  definite  and  permanent  contraction  at  the  pyloric 
orifice.  Its  greatest  distinctive  feature  is  the  constant  presence  of 
food  remains  in  the  fasting  stomach.  These  cases  are  described  in 
detail  under  the  heading  of  Benign  Pyloric  Stenosis. 

Stenosis  of  the  cardiac  end  of  the  stomach  may  occur  as  the  result 
of  cicatricial  contraction  at  that  point.  But  cases  of  cardiospasm  are 
frequently  observed  in  which  muscular  contraction  at  the  cardiac 
orifice  continues  without  abatement  for  years  after  the  healing  of  the 
ulcer  in  this  situation,  even  though  cicatrized  tissue  has  not  formed 
at  this  point.  It  is  probable  that  the  majority  of  cases  of  cardiospasm 
originate  in  this  way.  Stricture  of  the  duodenum  may  occur.  The 
contracting  band  may  be  thin  as  whipcord,  narrowing  the  bowel  as 
if  a  string  had  been  tied  around  it,  or  the  contraction  may  be  long 
and  tortuous,  forming  an  hour-glass  contraction  of  the  duodenum. 
W.  J.  Mayo  and  Moynihan  each  report  a  case  of  hour-glass  contrac- 
tion of  the  stomach  and  of  the  duodenum  in  the  same  patient.  The 
symptoms  of  obstruction  of  the  duodenum  resemble  those  of  pyloric 
stenosis.  If  the  contraction  be  above  the  papilla  a  difterential  diagnosis 
is  practically  impossible.  If  the  contraction  be  below  the  papilla  a 
diagnosis  is  made  by  the  constant  presence  of  food  remains,  together 
with  fresh  bile  in  the  fasting  stomach.  In  the  gastric  contents  it  may 
furthermore  be  possible  to  obtain  pancreatic  reactions.  Stricture  of 
the  duodenum  near  or  around  the  ampulla  of  Vater  may  involve  both 
the  common  bile  duct  and  the  canal  of  Wirsung.  Acute  or  chronic 
pancreatitis  may  result.  Jaundice  and  inanition  may  ensue,  and  a 
suspicion  of  malignant  disease  of  the  pancreas  may  be  entertained. 

Hour-glass  Contraction. — The  hour-glass  contraction  of  the  stomach, 
like  pyloric  stenosis,  is  rather  a  result  than  a  complication  of  gastric 
ulcer.  The  stomach  may  be  so  deformed  by  contracting  bands  as  to 
be  contracted  in  its  middle  zone  so  as  to  form  two  stomach  pouches, 
separated  by  a  contracted  opening  which  varies  greatly  in  size.  A 
similar  contraction  of  the  stomach  into  lateral  pouches  occurs  in  those 
cases  of  peritoneal  bands,  which  cross  the  stomach  and  form  a  line  of 
compression.  Allusion  has  just  been  made  to  these  cases.  By  multiple 
contractions  the  stomach  may  be  trilocular.    Moynihan  has  described 


172  ACUTE  AND  CHRONIC   ULCER 

a  case  in  which  by  multiplicity  of  bands  the  stomach  was  divided  into 
four  separate  sacs. 

Saddle-back  ulcers  on  the  lesser  curvature  are  more  frequently 
followed  by  hour-glass  contraction  than  are  any  other  form.  The 
symptoms,  physical  signs,  and  means  employed  in  diagnosis  are 
described  under  separate  headings. 

Phlegmonous  Gastritis. — Of  91  cases  of  phlegmonous  gastritis  col- 
lected by  Schnarrwyler,  with  additions  by  Robertson,  gastric  ulcer 
was  by  far  the  most  common  associated  lesion,  being  present  in  17 
of  the  cases. 

TREATMENT 

General  Measures. — Rest  and  protection  of  the  stomach  from  all 
mechanical,  chemical,  and  thermal  insults  are  the  indications  for  the 
medical  treatment  of  ulcers.  These  requirements  are  complied  with 
by  bodily  rest  and  a  carefully  selected  diet,  usually  preceded  by  a 
short  period  of  total  abstinence  from  all  food  and  drink. 

Bodily  Rest. — Bodily  rest  is  almost  essential  in  the  treatment  of 
ulcer,  not  only  because  the  mechanical  agitation  and  dragging  of  the 
ulcer  by  the  weight  of  the  food  during  locomotion  and  even  as  the 
result  of  the  upright  posture,  are  prevented,  but  because  we  can  begin 
our  diet  by  giving  scanty  quantities  of  food  and  drink  for  the  purpose 
of  throwing  the  minimum  amount  of  work  upon  the  stomach,  quantities 
at  first  so  insufficient  that  the  patient  would  be  unable  to  be  up  and 
about  without  unpleasant  or  even  serious  results. 

The  patient  should  be  kept  in  bed  from  two  to  four  weeks,  in  ordinary 
cases.  In  those  whose  symptoms  are  rebellious  to  treatment,  a  longer 
time  is  required.  Quiet  and  mental  repose  are  essential,  and  it  is 
occasionally  better  to  postpone  the  treatment  until  the  patient  can 
arrange  his  affairs  so  as  to  enter  upon  the  cure  with  tranquillity,  pro- 
vided too  long  a  time  is  not  demanded,  and  that  the  patient  in  the 
meantime  does  not  suffer  in  consequence.  As  a  rule,  however,  the 
sooner  the  treatment  is  begun  after  the  diagnosis  has  been  made,  the 
better  are  the  chances  for  ultimate  recovery.  Jni/  ircaimrnt  for  ulcer- 
that  does  not  include  absolute  rest  in  bed  is  but  a  half-hearted  treatment, 
and  will  obtain  only  partial  results.  No  delay  should  be  permitted  in 
cases  with  hemorrhages,  either  visible  or  occult,  or  in  those  patients 
whose  increase  of  j)ain  and  tenderness  suggest  the  possibility  of  im- 
pending disaster.  If  hemorrhage  be  recent,  the  re.st  must  be  absolute, 
and  tlu'  rising  cxcii  for  toilet  purposes  be  strictl\'  forbidden. 

External  Applications.  Kxtemal  ai)plications  are  to  be  employed 
(luring  the   first   few  weeks  of  treatment. 


TREATMENT  173 

In  cases  with  hemorrhage,  either  visible  or  occult,-  ice-bags  should 
be  applied  constantly  to  the  epigastrium,  so  as  to  promote  firm  con- 
traction of  the  bleeding  viscus.  Under  no  circumstances  should  hot 
applications  be  applied,  as  it  has  been  proved  conclusively  that  the 
application  of  external  heat  increases  the  congestion  of  the  stomach, 
and  is  frequently  followed  by  a  recurrence  of  the  hemorrhage.  The 
ice-bags  should  be  applied  until  all  traces  of  blood  have  disappeared 
from  the  stools. 

In  cases  icithotd  hemorrhage  moist  applications  are  to  be  employed, 
as  hot  as  can  be  given  or  endured.  Hot  poultices  or  flannel  or  spongio- 
piline  wrung  out  of  hot  water,  and  applied  every  half-hour,  may  be 
used,  and  are  especially  recommended  by  von  Leube,  who  insists  that 
retardation  of  the  healing  process  inevitably  results  when  less  extreme 
degrees  of  heat  are  employed.  Very  convenient  is  the  use  of  the 
electric  pad,  because  the  degree  of  heat  can  be  easily  regulated,  and 
the  number  of  attendants  diminished.  A  piece  of  moistened  flannel 
should  be  placed  under  the  pad,  and  the  whole  tightly  girded  by  an 
abdominal  binder. 

Lesser  degrees  of  heat  may  be  given  by  the  Priessnitz  compress.  A 
layer  of  flannel  or  a  piece  of  spongioline  about  ten  inches  square  is 
wrung  out  of  hot  water  and  covered  with  mosetig  batiste  or  oiled  silk, 
over  which  is  placed  a  folded  towel,  large  enough  to  overlap  the  edges 
of  the  cataplasm.  A  snug  abdominal  binder  is  then  applied.  If  the 
flannel  be  not  wrung  dry  enough,  it  will  drip  and  leak  upon  the  clothes 
and  bedding.  If  the  binder  be  not  tightly  applied,  air  will  get  up 
under  it  and  cause  chilling  of  the  surface.  The  pad  need  not  be 
changed  oftener  than  every  two  to  four  hours  in  the  day  and  once  in 
the  night.  It  is  not,  however,  as  effective  in  cure  as  the  more  extreme 
degrees  of  temperature. 

Abstinence. — In  cases  with  recent  hemorrhage,  either  visible  or 
occult,  it  is  usual  to  insist  upon  total  abstinence  from  all  food  and 
drink,  so  as  to  place  the  stomach  in  the  condition  of  complete  physio- 
logical rest,  and  this  abstinence  is  to  be  continued  until  all  traces  of 
blood  have  disappeared  from  the  stools.  Usually  this  occurs  by  the 
third  day,  but  although  the  hemorrhage  may  continue  longer  than 
this,  it  is  rarely  advisable  to  prolong  the  abstinence  period  for  more 
than  five  days,  although  in  extreme  cases  one  is  to  be  guided  by  the 
general  condition  of  the  patient.  The  abstinence  must  be  absolute; 
not  even  cracked  ice  should  be  allowed.  It  is  the  custom  of  many  to 
begin  the  ulcer  cure  by  a  period  of  abstinence,  even  in  those  cases 
that  are  not  attended  by  hemorrhage. 

During  the  period  of  abstinence,  there  is  much  less  discomfort  experi- 
enced than  one  would  imagine  possible.     The  chief  annoyance  is  thirst, 


174  ACUTE  AND  CHRONIC   ULCER 

but  l)\  the  use  of  constant  mouth  washes,  this  disagreeable  symptom 
is  rendered  (juite  enduralile.  The  sanitary  care  of  the  mouth  is,  more- 
over, of  great  importance  in  minimizing  the  danger  of  parotid  infection. 

Nutritive  Enemas.  —  Nutritive  enemas  are  frequently  employed 
during  the  period  of  starvation.  The  tube  should  not  be  inserted 
more  than  four  inches,  and  the  fluid  should  be  allowed  to  enter  slowly 
and  under  low  pressure,  stopping  if  pain  or  tenesmus  should  occur. 
Never  more  than  10  ounces  should  l)e  used  at  any  one  time,  and  not 
more  than  three  or  four  injections  are  to  be  given  daily.  The  temper- 
ature must  be  that  of  body  heat.  To  facilitate  retention,  the  pelvis 
may  be  elevated  by  pillows,  and  in  all  cases  a})solute  quiet  must  be 
enforced  following  the  injection. 

Solutions  of  peptone  (10  to  15  per  cent.),  egg-albumen,  peptonized 
milk,  sugar  solutions,  or  })oiled  starch  may  be  used — the  addition  of 
a  small  quantity  of  salt  seems  to  favor  absorption.  A  few  drops  of 
laudanum  or  of  the  deodorized  tincture  of  opium  may  be  added  should 
the  bowel  be  irritable. 

Ewald  recommends  an  enema  composed  of  two  tablespoonfuls  of 
flour  })()iled  with  150  c.c.  of  water  or  milk,  to  which  are  added  one 
or  two  eggs,  50  to  100  c.c.  of  a  15  to  20  per  cent,  solution  of  glucose, 
and  a  knife-point  of  salt. 

Boas'  enema  consists  of  250  c.c.  of  milk,  the  yolks  of  two  eggs,  one 
tablespoonful  of  red  wine,  one  tablespoonful  of  Kraftmehl,  a  knife- 
point of  salt,  and  5  drops  of  tincture  of  opium. 

The  writer  believes  that  the  value  of  nutrient  enemas  is  more 
from  the  quantity  of  licpiid  introduced  than  from  the  caloric  value 
of  the  ingredients,  as  but  little  of  luitrient  value  is  absorbed.  Albumin 
and  sugar  solutions  usually  add  to  the  putrefactive  processes  in  the 
bowel.  lie  further  believes  that  unless  enemas  are  called  for  to 
combat  depressant  symptoms,  they  do  more  harm  than  good,  by 
exciting  peristalsis  which  we  are  most  anxious  to  avoid.  He,  therefore, 
recommends  that  for  an  abstinent  period  of  from  three  to  five  days, 
enemas  of  initritive  value  be  not  given,  or  any  rectal  injections  of  any 
kind  unless  thirst  be  excessive  or  depressant  effects  of  the  abstinence 
become  evident.  Under  these  circumstances  there  may  be  given, 
injections  of  decinormal  solutions  of  sodium  bicarbonate,  in  prefer- 
ence to  salt  solution  usually  employed,  for  the  reason  that  it  more 
effectually  controls  thirst  and  combats  any  tendency  to  acidosis  from 
the  enforced  star\ation. 

The  continuous  instillation  of  the  soda  solution  is  preferable  to  the 
use  of  enemas,  using  any  of  the  modifications  of  the  INIurphy  drip, 
in  this  way  water  at  the  rate  of  a  pint  an  hour  can  be  introduced 
without    discomfort    and    without    exciting   peristalsis. 


TREATMENT  175 

Diet. — Various  diets  have  been  recommended  in  the  treatment  of 
ulcer,  both  during  the  actual  ulcer  cure,  and  also  during  the  period 
of  convalescence.  There  are  certain  characteristics  in  all  these  forms 
of  diet  which  must  be  insisted  upon. 

The  diet  mvst  he  sufficient  in  nutritive  value  to  prevent  emaciation. 

In  all  forms  of  diet  given  during  the  first  and  second  week  of  treat- 
ment, the  nutritive  value  is  not  sufficient  to  maintain  body  weight, 
and  there  usually  occurs  loss  of  from  six  to  ten  pounds.  During  the 
third  and  fourth  weeks  the  diet  is  usually  increased;  so  that  a  great 
portion  of  this  loss  is  recovered.  After  the  fourth  week  it  is  of  impor- 
tance to  maintain  this  body  weight,  without  further  loss,  no  matter 
what  form  of  diet  is  employed.  Prolonged  administration  of  milk  is 
unsuitable,  because  at  least  four  liters  must  be  given  daily  to  bring 
the  caloric  value  up  to  the  requisite  point. 

It  is  a  recognized  clinical  fact  that  the  healing  of  an  ulcer  is  regularly 
retarded  by  anemic  and  depressed  conditions  of  the  patient's  vitality, 
and  therefore  it  becomes  a  question  of  great  nicety  how  far  the  diet 
can  be  carried  without  detriment  to  the  patient's  ultimate  chances  of 
recovery.  Of  course,  in  deciding  this  point,  much  depends  upon  the 
general  condition  of  the  patient  at  the  time  when  the  treatment  is 
begun.  One  would  naturally  not  starve  an  anemic  and  depleted  patient 
to  the  same  extent  that  would  be  justifiable  in  one  who  is  robust  and 
plethoric. 

The  Daily  Qauntity  of  Food  Given  Must  Not  Be  Excessive. — One 
of  the  objects  of  the  treatment  of  ulcer  is  to  allow  the  stomach  to 
contract,  as  the  healing  process  proceeds  more  rapidly  under  these 
circumstances. 

Fleiner  writes  that  by  a  concentrated  diet  "we  render  it  possible 
for  the  stomach  to  shrink  to  its  smallest  compass.  The  edges  of  the 
ulcer  then  tend  to  approach  each  other,  and  the  deepest  portion  of 
the  ulceration  approaches  the  level  of  the  edges,  so  that  the  whole 
ulcer  becomes  smaller  and  more  shallow." 

A  diet  exclusively  of  milk  is  unsuitable,  as  distention  of  the  stomach 
is  bound  to  occur  if  enough  in  quantity  is  given  to  yield  sufficient 
nourishment  to  the  patient,  and  to  maintain  bodily  strength. 

Nourishment  Must  be  Non-irritating  and  Bland.  —  Coarse  and  irritat- 
ing articles  of  food  do  not  as  rapidly  pass  through  the  pylorus  as  does 
food  devoid  of  all  irritating  qualities,  and  the  longer  the  food  remains 
in  the  stomach,  the  greater  tendency  toward  hypersecretion  and  hyper- 
acidity. It  is,  moreover,  obvious,  that  by  unsuitable  diet,  we  add  to 
the  irritation  of  the  ulcer  and  prevent  its  healing. 

The  Diet  Should  Be  Such  as  to  Successfully  Combat  Hyperacidity. — 
With   this  object  in  view,  two  different  forms  of  diet  are  in  Aogue, 


176  ACUTE  AND  CHRONIC   ULCER 

one,  indorsed  by  von  Leube  and  the  majority  of  clinicians,  comprises 
bland  articles  of  food,  chiefly  carbohydrates,  which  require  the 
minimum  gastric  secretion,  the  other,  known  as  the  Lenhartz  diet, 
is  composed  of  concentrated  albuminous  foods  that  unite  well  with 
hj'drochloric  acid  in  the  gastric  juice  to  form  a  non-irritating  acid 
albumin.    These  two  diets  are  later  given  in  detail. 

Medical  Treatment. —  The  medical  treatment  of  ulcer  may  be  divided 
(1)  into  that  which  is  given  as  a  more  or  less  routine,  for  the  general 
purposes  of  facilitating  healing,  and  (2)  into  such  special  forms  of 
treatment  that  may  be  required  to  combat  distressing  or  urgent 
symptoms. 

General  Medicinal  Treatment. — Carlsbad  water  is  employed  by  many 
clinicians  as  a  routine  treatment,  and  is  especiallj'  advocated  by  von 
Leube.  A  glass  of  Carlsbad  water,  either  hot  or  lukewarm,  is  given 
in  the  fasting  condition  in  the  morning.  If  this  quantity  be  insufficient 
to  produce  a  daily  movement,  one  or  two  extra  doses  may  be  given 
during  the  day,  or  the  laxative  effect  of  the  morning  dose  may  be 
increased  by  the  addition  of  one-half  dram  to  a  dram  of  the  powdered 
salts.  If  the  natural  Carlsbad  water  cannot  be  obtained,  the  desiccated 
salts  prepared  by  Eisner  and  Mendelsohn  may  be  employed^ — 1  dram 
to  8  ounces  of  water  being  the  dose  ordinarily  used.  The  object  of 
the  Carlsbad  is  to  reduce  hyperacidity,  and  it  is  therefore  especially 
of  service  when  hyperacidity  or  hypersecretion  exist.  It  is  of  much 
less  value  in  ulcers  accompanied  l)y  normal  or  diminished  acidity. 

Silver  nitrate  is  a  drug  that  has  been  used  for  many  years  and  may 
be  employed  in  ulcers,  either  with  normal  or  increased  acidity,  as  an 
alternate  to  the  carlsbad  treatment.  The  usual  way  in  which  it  is 
given  and  the  one  employed  by  the  writer  is  to  give  three-sixths  of  a 
grain  in  distilled  water,  three  times  a  day,  one-half  hour  before  eating, 
for  three  days.  For  the  three  successive  days  the  dose  is  then  increased 
to  four-sixths  of  a  grain,  followed  by  a  further  increase  to  five-sixths 
of  a  grain  for  the  third  three-day  period.  This  nine-day  cycle  is  then 
repeated.  It  may  hap])en  that  diarrhea  will  occur  during  this  treat- 
ment. In  the  majority  of  instances  this  ceases  spontaneously,  but  if 
it  continues,  especially  if  the  patient  is  in  a  depleted  condition,  the 
medication  should  be  either  given  in  smaller  doses  or  totally  with- 
drawn. 

A  convenient  prescription  is: 

I^ — Argenti  nitrat gr.  xvj 

Aquae  destillatse 5ij 

M.     Sig. — 5  minims  equal  gr.  ,•. 

Dose — 15   to   2.5   minims   in   distilled   water,  three   times  daily  one-half  hour 
before  eating. 


TREATMENT  111 

The  silver  treatment  should  not  be  continued  for  more  than  four 
weeks.    At  the  end  of  a  similar  period  of  time  it  may  be  readministered. 

Chronic  indolent  ulcers,  especially  those  on  an  ambulant  treatment, 
are  often  impro\Td  by  lavage  with  1  to  3000  solution  of  silver  nitrate. 
Under  this  form  of  treatment  the  acidity  is  frequently  reduced,  and 
the  subjective  discomfort  and  pain  are  lessened.  It  is,  however,  doubt- 
ful whether  there  is  any  direct  result  on  the  healing  of  the  ulcer.  It 
may  be  necessary  to  abandon  the  treatment  should  diarrhea  ensue. 

Alkalies  are  imperative  if  hypersecretion  be  present.  Among  the 
antacids  may  be  mentioned  sodium  bicarbonate,  magnesia  usta,  mag- 
nesia carbonate,  bismuth  subcarbonate,  and  alkaline  waters,  of  which 
Celestins  Vichy  is  the  type.  Alkaline  powders  composed  of  antacids 
may  be  combined  in  a  variety  of  ways.  Bismuth  subcarbonate  is  of 
use  both  as  an  antacid  and  as  a  mechanical  protection  to  the  floor  of- 
the  ulcer.  It  is  given  in  suspension  in  water,  in  doses  proportionate 
to  the  acidity. 

Fleiner  recommends  the  bismuth  treatment,  should  pain  or  distress 
occur  when  the  diet  is  changed  from  fluid  to  semisolid,  or  from  semi- 
solid to  solid,  or  should  ulcer  symptoms  return  after  a  cure.  Given 
during  an  ulcer  cure,  the  bismuth  treatment  is  often  of  service;  but 
given  without  other  adjuvants  of  treatment,  such  as  a  rigid  diet  and 
bodily  rest,  it  can  only  serve  to  control  subjective  symptoms  of  pain 
and  discomfort  that  may  be  due  to  hyperacidity,  and  can  have  no 
direct  result  upon  the  healing  of  the  ulcer. 

Under  no  circumstances  should  bismuth  subnitrate  be  used,  as  the 
sharp  crystals  of  this  preparation  may  mechanically  irritate  the  floor 
of  the  ulcer. 

Oil,  either  pure  or  in  emulsion,  is  of  value  in  cases  of  ulcer  with 
hyperacidity  and  spasm  of  the  pylorus.  The  pure  olive  oil  may  be 
used,  or  in  more  sensitive  patients,  emulsion  of  sweet  almond  oil  may 
be  employed.  The  oil  treatment  is  given  less  in  active  ulcer  cure  than 
in  the  cases  of  ulcer  that  are  up  and  about  and  eating  solid  food.  The 
ordinary  dose  of  olive  oil  is  a  teaspoonful  half  an  hour  before  each  meal. 

Atropine  is  of  service  to  control  pain,  to  reduce  acidity,  and  to  relax 
muscular  spasm.  It  is,  therefore,  chiefly  employed  during  attacks  of 
acute  hypersecretion  from  pyloric  spasm. 

Treatment  of  Special  Symptoms. —  Hemorrhage. — The  drug  of  greatest 
service  is  adrenalin  in  10-minim  doses  of  1  to  1000  solution.  Such  a 
dose  may  be  given  every  quarter  to  every  half-hour,  diluted  in  a  small 
quantity  of  water.  Similar  results  follow  the  use  of  the  desiccated 
extract  in  2  to  10-grain  doses.  A  reaction  dilatation  may  follow  the 
vasomotor  constriction  which  adrenalin  produces  locally,  but  by  this 
time  a  thrombus  usually  becomes  firmly  fixed  at  the  bleeding-point. 
12 


178  ACUTE  AND  CHRONIC   ULCER 

Gelatin  may  be  given  either  as  a  rectal  injection  or  by  mouth,  a 
3  per  cent,  solution  being  usually  employed ;  given  by  rectum  one  or  two 
pints  may  be  employed.  A  dose  by  mouth  is  from  half  an  ounce  to 
two  ounces,  as  hot  as  can  be  borne,  is  given  every  half-hour  or  an 
hour,  provided  that  administration  is  not  followed  by  vomiting.  The 
writer's  results  with  gelatin  ha^'e  been  unsatisfactory. 

Ergotine  hypodermically  is  not  as  much  used  as  formerly. 

Calcium  chloride  in  20-grain  doses  may  be  given  by  rectum,  and 
is  especially  advised  by  Boas.  It  seems  of  use  only  in  repeated 
hemorrhages. 

All  attempts  at  vomiting  must  be  discouraged  so  as  to  prevent  the 
dislodgement  of  the  thrombus  that  is  nature's  method  of  relief.  ]\Ior- 
phine  may  be  given  hypodermically  to  quiet  nervous  apprehension 
and  restlessness,  provided  the  past  experience  of  the  patient  is  that 
opiates  do  not  cause  nausea  and  vomiting.  Apprehensive  relatives 
and  fussy  attendants  should  be  dismissed  from  the  sick  room. 

In  extreme  cases  in  which  hemorrhage  continues  in  spite  of  all 
methods  employed,  lavage  with  iced  water  has  been  recommended  by  as 
high  an  authority  as  Ewald.  Before  such  a  lavage,  the  patient  should 
receive  a  small  dose  of  morphine  hypodermically  and  the  throat  should 
be  sprayed  with  a  weak  solution  of  cocaine,  so  as  to  reduce  to  a  minimum 
any  attempt  at  vomiting.  The  washing  should  be  continued  until  it 
comes  almost  entirely  clear.  Any  increase  of  hemorrhage  during  this 
manipulation  has  not  occurred  in  Ewald's  experience.  An  ulcer  that 
is  not  about  to  perforate,  will  probably  not  be  affected  by  gentle 
lavage,  and  the  procedure  is  perfectly  justifiable  in  extreme  cases  of 
hemorrhage  after  other  measures  have  proved  useless. 

Bourjet  introduces  into  the  stomach  100  c.c.  of  a  1  per  cent,  solution 
of  ferric  chloride,  which  is  immediately  allowed  to  siphon  out  of  the 
stomach  again,  and  this  procedure  he  repeats  five  or  six  times  and 
claims  good  results  from  its  use.  Should  hemorrhage  be  sufficient  to 
cau.se  extreme  degrees  of  anemia,  liquids  must  be  introduced  into  the 
system  either  by  hypodermodysis,  or  in  less  urgent  cases  by  saline 
irrigations  or  the  ]\Iurphy  drip.  In  severe  cases  direct  transfusion 
should  be  resorted  to. 

]'omitlng. — Vomiting  is  usually  relieved  by  regulation  of  diet, 
oxalate  of  cerium,  small  doses  of  Fowler's  solution,  minim  doses  of 
carbolic  acid,  to  which  may  be  added  1  to  2  minims  of  dilute  hydro- 
cyanic acid.  Menthol  in  half-grain  doses  and  creme  de  menthe  frappe 
may  be  used,  but  are  not  of  any  service  in  the  acid  vomiting  of  hyper- 
secretion. IvcbcMious  cases  may  require  total  ai)stiiience.  The  vomiting 
of  acid  fluid,  indicating  hypersecretion,  usually  from  pyloric  spasm,  is 
treated  by  alkalies  in  large  doses,  and  atropine  pushed  to  mild  physio- 
logical limits.     If  the  xoniiting  dors  not  yield  to  this  treatment  gentle 


TREATMENT  179 

lavage  with  alkaline  solutions  is  far  safer  than  to  risk  hemorrhage  from 
the  strain  of  repeated  emesis.  Abstinence  from  food  is  indicated  during 
acute  hypersecretion. 

Pain. — Pain  is  regularly  relieved  during  the  first  week  of  an  ulcer 
cure  if  the  ulcer  be  without  complications.  Heat  is  distinctly  calma- 
tive to  pain,  while  alkalies  relieve  by  reducing  the  acidity.  Pain  from 
adhesions  may  be  alleviated  by  rest  and  hot  applications  and  by  giving 
food  in  small  quantities  at  a  time.  If  pain  should  continue  after  the 
tenth  day  of  an  active  ulcer  treatment  we  are  confronted  either  with 
complications,  or  the  case  is  one  of  mistaken  diagnosis — to  this  rule 
there  are  but  few  exceptions. 

Perforation  is  a  purely  surgical  complication,  and  immediate  resource 
should  be  had  to  laparotomy.  There  are  undoubtedly  cases  of  spon- 
taneous cure,  but  these  should  be  regarded  as  medical  curiosities  and 
should  not  allow  us  to  waste  valuable  time  by  an  ineffective  medical 
treatment. 

Individual  Methods  of  Treatment. — Each  writer  of  experience  has 
his  own  method  of  treatment  which  to  him  has  yielded  the  best  results. 
While  the  general  rules  of  treatment  are  applied  in  all  these  individual 
methods,  the  details  of  management  vary  s  omewhat,  and  it  seems  wise 
to  describe  two  methods  most  popular  at  the  present  time,  and  to  add 
the  method  of  treatment  preferred  by  the  author  and  commonly 
employed  by  him. 

von  Leube's  Treatment. — The  patient  remains  in  bed  the  first  ten 
days.  On  the  eleventh  day  he  is  allowed  to  be  up  and  about,  although 
lying  down  for  one  or  two  hours  after  each  meal  is  insisted  upon  for  a 
number  of  weeks  afterward,  von  Leube  claims  never  to  have  seen 
bad  results  by  letting  the  patient  leave  his  bed  as  early  as  this,  either 
in  the  return  of  pain  or  in  the  retardation  of  the  healing  process.  During 
this  time  poultice  applications  as  hot  as  can  be  given  are  applied  every 
ten  or  fifteen  minutes  during  the  day,  while  the  Priesnitz  application 
is  applied  at  night.  A  preliminary  sterilization  of  the  skin  is  advised 
to  prevent  infection  from  any  possible  blisters  that  may  be  caused  by 
the  extreme  heat. 

Should  blisters  occur,  the  skin  should  be  washed  with  ether  and 
followed  by  an  application  of  dermatol.  These  hot  applications  are 
to  be  used  only  in  cases  without  visible  hemorrhage.  Should  occult 
bleeding  be  present,  extreme  heat  is  undesirable  and  the  Priesnitz 
application  should  be  employed. 

In  all  cases  of  recent  hemorrhage,  local  applications  of  ice-bags  to 
the  epigastrium  are  to  be  employed  until  the  stools  show  that  the 
bleeding  has  ceased.  When  this  occurs  the  ice  is  discontinued  and 
moderate  heat  by  the  Priesnitz  method  is  employed.  Extreme  heat  is 
not  to  be  employed  for  at  least  three  months  after  acute  hemorrhage. 


ISO  ACUTE  AND  CHRONIC  ULCER 

A  glass  of  lukewarm  Carlsbad  water  is  given  every  morning  in  the  fast- 
ing state,     von  Leube  believes  in  its  healing  qualities  in  cases  of  ulcer. 

Few  drugs  are  used  except  bismuth  or  sodium  bicarbonate.  Alkaline 
waters  may  be  taken.  Constipation  is  relieved  by  an  enema  of  Carls- 
bad salts,  or,  after  the  eleventh  day,  by  a  teaspoonful  of  a  powder 
composed  of  pulv.  rhei  20  parts,  sodium  sulphate  15  parts,  sodium 
bicarbonate  7.5  parts.    The  diet  during  this  treatment  is  as  follows: 

Patients  with  recent  hemorrhages  are  treated  by  nutritive  enemas 
for  the  first  three  days,  after  which  they  begin  the  diet  upon  which 
patients  without  hemorrhages  are  placed  at  once. 

For  the  first  ten  days  small  quantities  of  boiled  milk,  meat  extract, 
soup,  and  unsweetened  biscuits  are  given.  The  fourth  day  the  patient 
receives  2|  pints  of  milk,  6  ounces  of  rusk  or  zwiebach,  and  some  meat 
extract.  In  the  next  seven  days  gelatinous  soups,  rice,  sago  boiled  with 
milk,  raw  and  soft-boiled  eggs,  boiled  calves'  brains,  and  broiled  chicken 
and  pigeon  without  fat  or  skin  are  added.  In  the  next  five  days  the 
diet  is  increased  by  rare  steak  finely  minced,  potatoes,  puree  rice 
soups,  and  weak  tea  and  coffee. 

During  the  third  and  fourth  week  there  are  given  tender  beef,  roast 
chicken  and  pigeon  and  squab,  well-cooked  venison  or  partridge, 
macaroni,  and  the  soft  part  of  white  bread.  From  the  fifth  week 
onward  a  return  is  gradually  made  to  ordinary  food. 

Lenhartz  Treatment. — The  Lenhartz  treatment  is  based  on  the  belief 
that  the  weakening  of  the  patient  by  too  strict  enforcement  of  a  rigid 
and  insufficient  diet  so  undermines  recuperative  processes  that  the 
proper  healing  of  the  ulcer  is  prevented.  Small  repeated  feedings  are 
begun  with  im])unity  even  after  recent  hemorrhage,  and  there  is  given 
a  concentrated  albuminous  diet  which  converts  free  hydrochloric  acid 
into  the  loosely  combined  form,  and  prevents  further  erosion  and 
irritation  of  the  ulcerated  area. 

The  requisite  course  of  treatment  extends  over  two  weeks.  Al)solute 
rest  in  bed  is  insisted  upon.  Local  applications  of  ice-bags  are  employed 
during  the  first  ten  da>s.  He  recommends  the  use  of  bismuth  subcar- 
l)()iiatc  in  .'^)0-grain  doses  three  times  a  day.  Chronic  ulcers  with 
l)ron(>unc('d  pain  are  treated  by  sihcr  nitrate  and  by  a  limitation  of 
lifjuids.  Bland  j)reparations  of  iron  are  gi^•en  if  anemia  is  present. 
'\hv  following  articles  of  fliet  are  given: 

Fresh  milk,  iced;  l)()tli  milk  and  eggs  placed  in  a  glass  tumbler,  sur- 
rounded with  cracked  ice,  and  kept  at  the  bedside — even  the  feeding 
spoon  is  kept  iced  at  the  same  time.  '^Fhe  eggs  and  milk  may  be  given 
alternately  in  lionrly  dos<'s,  or  may  be  mixed  and  given  together. 
Granulated  sugar  is  added  to  the  eggs  after  the  tiiird  dax'.  Uaw  scraped 
beef;  boiled  rice  and  zweibach  are  gi\en  later.    According  to  the  follow- 


T  RE  ATM  EXT 


181 


ing  schedule,  cooked  chicken  finely  chop]K'd,  chopped  ham  or  heef  are 
added  with  butter  and  gi\en  in  large  doses.  After  the  tenth  day 
broiled  chop  or  steak  may  be  substituted  for  the  scraped  meat;  toasted 
bread  may  replace  the  zwiebach,  and  fine  cereals  may  take  the  place 
of  the  rice.  During  the  first  ten  days  rigid  adherence  to  routine  is 
insisted  upon,  both  as  regards  the  quantity  of  each  article  of  diet 
given  at  each  feeding  and  to  the  totals  of  each  article  for  the  twenty- 
four  hours.  The  food  is  given  in  hourly  intervals  from  7  a.m.  to  9 
P.M.,  and  a  complete  rest  of  ten  hours  is  allowed  during  the  night. 
Beef  broths  are  contra-indicated,  owing  to  the  extractives  and  spices 
which  tend  to  induce  hyperacidity.  Lenhartz  begins  his  diet  in  a  few 
hours  even  after  severe  and  repeated  hemorrhages,  and  claims  to  have 
no  disastrous  results  from  this  early  feeding.  The  details  of  his  diet 
are  given  in  the  following  table: 


Day. 


Eggs. 


Milk. 


Sugar. 


Scraped  Beef. 


I    2  drams    per    dose; 

total,  2  eggs. 

II    3    drams   per    dose; 

total,  3  eggs. 

III  I    ounce    per    dose; 

total,  4  eggs. 

IV  5    drams   per   dose; 

total,  5  eggs. 
V    6   drams   per   dose; 

total,  6  eggs. 

VI    7    drams   per   dose; 

total,  7  eggs. 

VII  4  drams  per  dose; 
total,  4  eggs.  Also 
1  soft-boiled  egg 
every  four  hours; 
total,  4  eggs. 

VIII  4  drams  per  dose; 
total,  4  eggs.  Also, 
1  soft-boiled  egg 
every  four  hours; 
total,  4  eggs. 
IX  4  drams  per  dose; 
total,  4  eggs.  Also, 
1  soft-boiled  egg 
every  four  hours; 
total,  4  eggs. 
X  4  drams  per  dose; 
total,  4  eggs.  Also, 
1  soft-boiled  egg; 
every  four  hours ; 
total,  4  eggs. 


4  drams  each  dose; 

total,  6  ounces. 
6   drams   per   dose; 

total,  10  ounces. 

1  ounce    per    dose; 
total,  13  ounces. 

1|  ounces  per  dose; 

total,  1  pint. 
14  drams  per  dose; 

total,  19  ounces. 

2  ounces  per  dose; 
total,  22  ounces. 

2   ounces  per  dose; 
total,  25  ounces. 


2§  ounces  per  dose; 
total,  28  ounces. 


3  ounces  per  dose; 
total,  1  quart. 


Add  cooked  chopped    40  grams, 
chicken,  50  grams, 
also    butter,  20 
grams. 


20  grams  added 

to  eggs. 
20  grams  added 

to  eggs. 
30  grams. 

40  grams. 

40  grams. 


40  grams. 


36  grams  in  3 

doses. 
70  grams  with 

boiled  rice, 

100  grams  in 

3  doses. 

70  grams  with 
boiled  rice, 
100  grams  in 
3  doses. 

Beef  same;  rice 
200     grams. 
Zweibach,    40 
grams     in     2 
portions. 

Beef  same;  rice 
200     grams. 
Zwiebach,    40 
grams     in     2 
portions. 


XI  to  XIV.  Interval  of  feeding  made  two  hours,  milk  given  in  6-ounce  doses,  with 
5  ounce  of  raw  egg.  Butter  increased  to  40  grams  and  various  additions  made,  as 
detailed  above. 


182  ACUTE  AND  CHRONIC   ULCER 

By  this  treatment  Lenhartz  claims  a  mortality  of  from  2  to  3  per  cent., 
and  states  that  the  recurrences  of  hemorrhage  are  less  frequent  than  in 
other  forms  of  treatment. 

Springs/  however,  has  followed  21  cases  treated  by  the  Lenhartz 
method ;  9  had  a  definite  return  of  symptoms  of  ulcer,  and  3  complained 
of  constant  indigestion. 

Of  the  two  forms  of  treatment,  von  Leube's  and  Lenhartz',  the  writer 
believes  that  better  results  are  obtained  by  the  former  than  by  the 
latter  in  the  average  run  of  ulcer  cases;  but  that  when  patients  are 
debilitated  by  hemorrhage,  by  insufficient  nourishment,  or  by  pro- 
longed or  recurrent  vomiting,  the  abstinent  treatment  and  insufficient 
diet  during  the  first  week  or  ten  days  of  von  Leube's  treatment  tend 
to  lower  the  vitality  of  the  patient  to  such  a  point  that  recuperative 
processes  are  held  in  abeyance.  It  is  in  this  class  of  cases  that  the 
Lenhartz  treatment  is  particularly  advantageous. 

Writer's  Method  of  Treatment. — The  patient  is  kept  in  bed  for  four 
weeks.  During  the  first  ten  days  he  is  not  allowed  to  arise  even  for 
toilet  purposes.  This  enforcement  of  body  rest  is  an  essential  of  the 
treatment. 

Treatment  fur  the  First  Three  Days. — Absolute  abstinence  is  enjoined 
for  the  first  seventy-two  hours  in  all  cases,  whether  or  not  hemorrhage 
or  occult  bleeding  be  present.  The  patient  eats  nothing  after  his 
dinner  the  night  before  beginning  treatment,  so  that  the  last  twelve 
hours  of  starvation  are  passed  in  the  day  rather  than  in  the  night. 

During  these  three  days  mouth  washes  are  used  frequently,  to 
minimize  mouth  sepsis  and  to  assuage  the  feeling  of  thirst.  A  cleansing 
enema  is  given  early  in  the  first  day.  Nutritive  enemas  are  not 
employed,  nor  is  enteroclysis  advised  except  in  the  case  of  those  who 
are  weakened  l)y  hemorrhages,  insufficient  nourishment,  recurring 
vomiting,  or  who  are  constitutionally  in  a  condition  of  lowered  vitality. 
Decinormal  solutions  of  sodium  bicarbonate  are  preferable  to  the 
saline  solutions  usually  recommended  for  the  reasons  previously  given, 
and  the  fluid  is  best  introduced  by  some  one  of  the  modifications  of 
the  Murphy  drip.  Li  milder  cases  in  which  the  only  indication  is  to 
relieve  thirst,  retention  enemas  of  the  soda  solution  may  be  given. 

Drugs  during  this  period  are  but  rarely  used,  exceptions  being  made 
in  the  case  of  recent  hematemesis  or  occult  bleeding,  and  in  cases  of 
continuous  secretion  with  or  without  acid  vomiting. 

During  the  entire  period  of  treatment  hot  moist  applications  are 
to  be  em[)loyed,  except  when  visible  hemorrhage  has  occurred  at  any 
time  within  the  previous  three  weeks,  and  the  hotter  they  can  be  used 

'  Kritisli  Medical  Journal.  April  .'i  1909,  p.  ,S25. 


TREATMENT  183 

the  better.  The  writer  has  never  used  such  extreme  degrees  of  heat 
as  von  Leube,  who  appHes  hot  poultices  every  ten  to  fifteen  minutes 
throughout  the  day,  but  who  continues  this  treatment  for  only  ten 
days.  The  writer  recommends  only  such  heat  that  can  be  used  without 
excessive  discomfort,  using  the  electric  pad  by  preference  day  and 
night,  or  when  this  cannot  be  employed,  the  Priesnitz  application, 
changed  every  hour  during  the  day,  twice  at  night  in  the  first  two 
weeks,  and  once  at  night  in  the  latter  half  of  the  treatment.  The 
external  application  must  be  continued  at  least  one  month. 

In  cases  of  visible  and  evident  hemorrhage,  ice-bags  are  to  be  applied 
constantly  until  all  traces  of  blood  have  disappeared  from  the  stools, 
and  are  to  be  then  succeeded,  not  by  extreme  heat,  but  by  the  Priesnitz 
applications,  not  hot,  but  warm  and  reapplied  only  every  six  hours. 

Treatment  from  the  Fourth  to  the  Seventh  Day. — Fourth  day:  At 
the  end  of  seventy-two  hours  feeding  by  mouth  may  be  begun,  b}^ 
giving  peptonized  milk  in  2-ounce  doses,  and  a  similar  quantity  of 
Celestins  Vichy  or  of  a  solution  of  sodium  bicarbonate,  gr.  v  to  2  oz. 
water  on  the  intervening  hours,  so  that  the  patient  receives  2  ounces 
of  liquid  every  hour.  Sleep  must  not  be  interfered  with.  On  the  fifth 
day  these  quantities  are  increased  to  3  ounces,  on  the  sixth  day  to  5 
ounces,  on  the  seventh  day  the  milk  is  increased  to  7  or  8  ounces, 
while  the  alkaline  water,  given  at  the  same  stated  periods,  is  reduced 
in  quantity  to  suit  the  desire  of  the  patient. 

The  author's  method  of  peptonization  to  be  recommended: 

To  1  pint  of  milk  is  to  be  added  f  pint  of  water,  and  the  mixture  is 
to  be  divided  into  two  equal  parts.  Boil  one  part,  and  immediately 
afterward  add  the  other.  Stir  in  the  contents  of  one  of  Fairchild's 
peptonizing  tubes,  and  set  the  bottle  in  warm  water  for  one  and  one- 
quarter  hours.  Bring  rapidly  to  a  boil  and  keep  on  ice.  The  completely 
peptonized  milk  should  have  a  slightly  bitter  but  not  unpleasant  taste. 

No  drugs  are  usually  employed  during  this  period  unless  indicated 
to  meet  special  conditions,  such  as  acidity,  vomiting,  or  hemorrhage. 
External  applications  are  continued.  The  bowels  are  moved  daily 
by  single  enemas. 

Should  the  patient  be  one  who  is  habituall,y  constipated,  Carlsbad 
treatment  may  be  begun. 

Treatment  during  the  Second  Week. — The  diet  may  now  be  enlarged 
by  the  substitution  of  the  following  articles  for  any  one  of  the  doses 
of  milk:  Junket,  arrowroot  gruel,  milk  toast,  creamed  macaroni, 
malted  milk,  blanc  mange,  farina,  and  hominy  or  cream  of  wheat  with 
cream  and  sugar.  Not  more  than  5  ounces  of  any  one  of  these  should 
be  given  at  any  one  time,  and  the  system  of  two-hour  feedings  continued. 
Onlv  one  article  is  siven  at  a  time.     Celestins  Vichv  or  the  soda  solu- 


184  ACUTE  AND  CHRONIC   ULCER 

tioii  may  be  taken  as  often  as  desired,  but  not  in  jijreater  quantity  than 
4  ounces  at  any  one  time.    External  applications  are  to  be  continued. 

Two  methods  of  medication  may  be  employed:  the  Carlsbad 
treatment  and  that  by  silver  nitrate.  The  details  of  both  forms  of 
treatment  have  been  previously  described  (see  p.  176).  Between  these 
two  forms  of  medication  the  writer  sees  very  little  to  choose,  results 
seeming  to  about  the  same  with  one  as  with  the  other.  The  Carlsbad 
treatment  is  generally  to  be  given  the  preference  to  those  who  are 
habitualh'  constipated  and  flatulent,  with  coated  tongue  and  other 
evidences  of  hepatic  insufficiency.  The  silver  nitrate  cycle  seems  to 
be  indicated  especially  in  these  ulcers,  with  clean  tongues  and  regular 
bowel  functions,  which  are  accompanied  by  a  heightened  acidity,  and 
usually  with  persisting  pain. 

Treatment  diirimj  Third  Week. — During  the  third  week  the  only 
change  is  in  the  enlargement  of  the  diet,  there  l)eing  gradually  added 
mashed  potatoes,  purees  of  any  kind  not  made  with  meat  stock,  creamed 
or  boiled  fresh  fish,  soft  boiled  or  poached  eggs,  the  soft  part  of  pump- 
kin pie,  custard,  and  mashed  vegetables  that  can  be  put  through  a 
puree  sieve.  Soft  bread  well  masticated  or  crackers  are  allowed. 
Several  articles  of  diet  may  be  given  at  a  time,  and  the  feeding  interval 
may  be  lengthened  to  every  three  hours.  During  the  third  week  milk 
is  usually  discontinued. 

Treatment  during  Fourth  Week. — During  the  fourth  week  the  jjatient 
is  allowed  to  sit  up  a  portion  of  each  day,  and  the  external  applications 
are  gradually  diminished.  The  only  other  change  in  the  treatment 
is  the  addition  of  creamed  chicken,  tender  squab,  lean  boiled  ham,  and 
minced  veal.  Should  anemia  be  present,  iron  in  some  bland  form  ma}' 
be  given.  Given  earlier  than  this  in  the  treatment  it  is  not  generally 
well  borne.  Strychnine,  nux  vomica,  or  eserine  are  frequently  valuable 
adjuncts. 

After-treatment. — The  diet  of  the  fourth  week  is  to  be  contiiuied  for 
at  least  a  month  before  resumption  of  a  more  varied  menu,  the  quantity 
given  at  any  one  time  may  be  gradually  enlarged,  so  that  the  patient 
is  allowed  three  larger  meals  and  two  smaller  meals  a  day.  Plating 
at  night  is  not  recommended.  For  at  least  six  months  red  meat," 
scratchy  articles  of  food,  raw  fruit,  and  fruit  juices,  ice  cream,  ice 
water,  and  all  highly  seasoned  and  spic>'  articles  of  food  must  be  for- 
bidden. A  little  whisky  and  water  at  dinner  may  be  allowed,  but 
cocktails,  champagne,  and  the  heavier  wines  nuist  be  prohibited. 
Smoking  should  l)e  in  moderation  and  only  after  fating.  Tea  is  unad- 
visal)lc;  weak  coffee,  especially  caffeine-free  cofl^'ee,  such  as  the  "Dekafa" 
of  Merck  ik  Co.,  hirgely  diluted  with  milk  is  allowed  iit  breakfast  only. 

The  author's  convalescent  ulcer  diet  is  here  given: 


TREATMENT  185 

Breakfast.  Fine  cereal,  with  cream  and  sii.uar,  such  as  farina,  vitos, 
hominy,  toasted  corn  fiaivcs.  Coarse  cereals,  such  as  oatmeal  and 
cracked  wheat,  not  allowed.  No  dry  toast,  bread  crusts,  or  hot  bread. 
May  have  soft  parts  of  bread,  milk,  or  cream  toast,  or  crackers  thor- 
oughly masticated.  No  tea  or  coft'ee.  May  have  cocoa  with  cream 
and  sugar;  milk  or  malted  milk.    Two  soft-boiled  or  poached  eggs. 

11  A.M.  Choice  of  malted  milk,  junket,  cup  custard;  top  milk  or 
cream,  or  milk  and  cream.  Egg  shake  without  wine  or  brandy.  Russell's 
emulsion.  Two  raw  eggs.  Puree  of  any  kind,  made  without  meat  stock. 
'Luncheon:  Puree  of  any  kind  made  without  meat  stock.  Oysters 
in  any  form;  if  raw,  to  be  taken  with  only  a  little  lemon  juice.  Creamed 
or  milk  toast.  Creamed  or  boiled  fresh  fish.  Mashed  or  baked  pota- 
toes, without  pepper.  Spaghetti  or  macaroni.  Creamed  or  minced 
chicken.  Butter  should  be  taken  freely,  preferably  unsalted.  Farina- 
ceous dessert,  such  as  farina,  tapioca,  corn-starch,  blanc  mange,  rice 
pudding,  custard.  No  ice-cream,  fruit  ices,  cakes,  or  fruit  of  any 
kind. 

4  to  5  P.M.  Same  variety  as  at  11  a.m.,  but  may  have  additional 
choice  of  cocoa  with  cream  and  sugar,  or  a  farinaceous  dessert.  No 
tea  allowed. 

Dinner.    Same  variety  as  at  luncheon. 

10  P.M.     Same  variety  as  at  4  p.m. 

Water  to  be  scanty  at  meals,  cool  but  never  iced.  Celestins  or 
Saratoga  Vichy  preferably  to  pure  water. 

No  wines  or  alcohol  in  any  form. 

Smoking  allowed  only  in  the  greatest  moderation,  and  never  between 
meals. 

In  those  cases  in  which  the  silver  cycles  were  administered  this 
drug  should  be  discontinued  after  the  fourth  week  and  the  Carlsbad 
treatment  substituted.  In  those  treated  primarily  by  the  Carlsbad 
salts,  this  should  be  continued.  It  is  more  convenient  and  equally 
efficacious  to  reduce  the  dosage  to  one  hot  glassful  one-half  hour  before 
breakfast. 

Treatment  of  Hemorrhage. — Single  large  hemorrhages  are  best 
treated  medically.  Operative  interference  either  is  not  necessary  or 
the  patient  is  so  exsanguinated  as  to  render  an  operation  of  such 
magnitude  unjustifiable.  Abstinence  from  all  food  or  drink  should  be 
absolute.  Ice-bags  are  to  be  applied  to  the  epigastrium  to  promote 
firm  contraction  of  the  stomach.  The  general  methods  of  combating 
syncope  and  other  symptoms  of  acute  profound  anemia  are  to  be 
resorted  to,  such  as  lowering  of  the  head,  elevation  of  the  foot  of  the 
bed,  and  the  giving  of  liquids  subcutaneously  or  by  the  bowel. 

Morphine  is  to  be  given  only  when  there  are  frequent  attempts  at 


186  ACUTE  AND  CHRONIC   ULCER 

vomiting  or  whenever  restlessness  and  apprehension  prevent  the 
mental  and  body  quietude  that  are  necessary  to  promote  the  formation 
of  a  clot  at  the  bleeding  point. 

Adrenalin  is  the  one  drug  which  seems  serviceable.  The  solution  of 
adrenalin  chloride  (1  to  1000)  may  be  given  in  10-minim  doses  every 
hour.  The  reaction  dilatation  of  the  bloodvessels  that  follows  its  use 
need  not  be  considered  in  acute  hemorrhages. 

Gelatin  has  not  seemed  to  be  of  service.  It  may,  however,  be 
employed  in  3  per  cent,  solution  by  rectum.  Given  in  this  way  it  can 
do  no  harm,  possibly  a  little  good,  while  the  effect  of  introducing 
liquids  into  the  system  by  use  of  such  a  solution  is  often  useful  in 
moderating  the  severity  of  the  symptoms  of  exsanguination.  Gelatin 
by  mouth  is  not  to  be  recommended,  as  it  violates  the  principles  that 
nothing  should  be  allowed  to  enter  the  stomach  during  the  time  of 
active  hemorrhage. 

Should  the  hemorrhage  continue  in  spite  of  the  above  treatment, 
and  the  patient  be  accustomed  to  the  tube,  gentle  lavage  with  ice 
water  may  be  used  and  continued  until  the  return  flow  is  nearly  clean. 
If  the  patient  be  left  in  an  exhausted  condition  the  Lenhartz  diet  may 
be  given  as  soon  as  bleeding  ceases. 

Chronic  hemorrhages  are  to  be  treated  by  gelatin  by  mouth  in 
doses  of  a  3  per  cent,  solution  every  hour  or  so,  by  calcium  chloride 
in  20-grain  doses  by  rectum  every  four  hours.  Adrenalin  is  not  to 
be  employed  for  any  length  of  time,  owing  to  the  vasomotor  dilata- 
tion that  may  follow  its  prolonged  use.  The  continuance  of  repeated 
hemorrhages  during  a  liquid  diet  may  render  operation  advisable. 

The  subcutaneous  injection  of  blood  serum  which  has  given  such 
striking  results  in  hemorrhagic  diseases  of  the  newborn,  has  apparently 
been  of  great  benefit  in  the  control  of  hemorrhage  from  gastrin  and 
intestinal  ulceration.  Human  serum  whose  suitability  has  been  pre- 
viously tested,  as  for  transfusion,  is  l)est,  although  when  such  tests 
cannot  be  made,  as  in  emergencies,  untested  serum  may  be  used,  as 
the  risk  involved  from  hemolysis  and  agglutination  is  probably  very 
slight.  Xext  best  in  order  of  safety  are  rabbit  and  horse  serum.  When 
they  are  used  the  danger  of  anaphylaxis,  though  somewhat  remote, 
must  be  borne  in  mind. 

From  10  to  15  c.c.  of  serum  are  injected  at  one  time,  and  this  injec- 
tion may  be  repeated  on  successive  days,  if  necessary,  or  even  at 
shorter  intervals.  The  blood  is  ol)tainc(l  under  the  strictest  aseptic 
precautions  from  a  superficial  vein,  and  collected  in  sterile  flasks 
which  are  kept  on  ice  until  the  serum  has  suflficiently  separated.^    This 

'  Wflch'.s  tccliniquc  may  Ix'  found  in  Amcr.  .lour.  Mod.  Sci.,  cxxxix,  213. 


TREATMENT  187 

is  best  done  by  one  who  has  had  experience  in  serolog}^  The  effect 
of  the  serum  treatment  prol)ab]y  begins  about  six  or  eight  hours  after 
the  injection,  and  lasts  for  several  da.ys. 

In  urgent  cases  of  hemorrhage  direct  transfusion  of  blood  is  indi- 
cated. 

Occult  Bleeding. — The  stools  should  be  tested  for  the  presence  of 
occult  blood  at  least  every  three  days  during  the  first  fortnight.  The 
presence  of  blood  traces  during  this  period  indicates  that  the  ulcer  is 
not  properly  healing,  and  that  no  further  increase  in  the  diet  is  per- 
missible, provided  that  the  meagreness  of  the  diet  is  not  carried  to 
such  an  excess  as  to  reduce  to  too  low  an  ebb  the  vitality  of  the  patient, 
and  thus  to  retard  the  healing  process.  Every  radical  change  in  diet — 
the  substitution  of  semisolid  for  liquid  food,  or  the  giving  of  solids 
instead  of  soft  or  semisolid  nourishment,  is  to  be  continued  only  when 
such  a  change  is  not  followed  by  a  positive  return  of  the  blood  test. 
Should  the  occult  bleeding  persist  in  spite  of  a  diet  that  is  inadequate 
to  maintain  a  proper  preservation  of  bodily  flesh  and  strength,  the 
patient  should  at  once  be  placed  upon  the  Lenhartz  treatment,  which 
should  be  continued  no  matter  what  may  be  the  reaction  of  the  blood 
test. 

If  during  the  third  and  fourth  week  bleeding  continue,  suspicion 
should  always  be  entertained  of  beginning  malignancy.  Record  of 
blood  counts  and  of  body  weight  must  be  systematically  reported. 
Loss  of  weight  or  progressive  diminution  in  the  percentage  of  hemo- 
globin during  the  second  month  of  treatment,  with  or  without  posi- 
tive blood  reactions,  afford  sufficient  reason  for  advocating  surgical 
exploration. 

Treatment  of  Hypersecretion. — If  chronic  hypersecretion  is  present 
it  is  rarely  sufficiently  pronounced  to  demand  any  special  treatment 
during  the  first  three  days,  and,  moreover,  it  usually  subsides  entirely 
after  the  giving  of  food  is  discontinued.  Should  the  patient  complain 
of  hyperacidity  and  heart-burn,  small  doses  of  milk  of  magnesia  may 
be  given,  or  bismuth  subcarbonate  in  suspension,  giving  only  such 
quantities  as  may  be  necessary  to  relieve  the  burning. 

Ac2de  Hypersecretion. — The  treatment  of  acute  hypersecretion,  with 
burning  and  distress,  and  the  vomiting  of  acid  watery  fluid  is  the  same 
whether  it  occurs  during  the  first  three  days  or  later  in  the  course 
of  treatment.  Rest  to  the  stomach  and  doses  of  alkalies  sufficient 
to  neutralize  the  acid  are  the  essentials  of  the  treatment.  Sodium 
bicarbonate  may  be  an  ingredient  of  any  of  the  combinations  of  alkalies 
administered,  but  should  only  be  given  in  small  quantities,  as  the 
resulting  liberation  of  carbon  dioxide  may  cause  the  overdistention 
of  the  stomach,  which  we  are  anxious  to  avoid. 


188  ACUTE  AND  CHRONIC   ULCER 

Gentle  Unage  with  weak  alkaline  solutions  may  be  employed  in 
cases  of  excessi\e  vomiting,  especially  if  the  patient  be  accustomed 
to  the  use  of  the  tube,  and  at  the  close  t)f  the  procedure  an  ounce  of  a 
3  per  cent,  solution  of  anesthesin  in  olive  oil  may  be  introduced.  I'nless 
idiosyncrasy  exist,  atroj)ine  should  always  be  given  subcutaneously 
in  doses  sufficient  to  cause  mild  physiological  effects,  even  though 
annoying  dryness  of  the  tongue  be  increased  by  its  use.  It  is  only 
when  the  severity  of  the  attack  becomes  modified  that  the  drug  ma\' 
be  given  by  mouth,  either  as  the  alkaloid  itself  or  in  the  form  of  tinc- 
ture of  belladonna.  When  hypersecretion  cease,  the  drug  is  to  be 
withdrawn — its  use  as  a  routine  procedure  as  recommended  by  some 
writers  is  not  to  be  advised. 

Einhorn  has  devised  a  method  of  feeding  which  he  terms  duodenal 
alimentation.  His  apparatus  consists  of  a  perforated  aluminum 
capsule  to  which  is  attached  a  thin,  soft,  India-rubber  tube  having 
three  markings:  the  first  indicating  the  distance  from  the  dental  arcade 
to  the  cardia;  the  second,  from  the  dental  arcade  to  the  pylorus,  and 
the  third  mark  indicating  the  distance  from  the  dental  arcade  well 
into  the  duodenum. 

The  capsule  is  to  be  swallowed  at  night,  the  end  of  the  tube  being- 
attached  by  a  piece  of  plaster  to  the  cheek.  The  following  morning 
it  is  to  be  hoped  that  the  capsule  is  in  the  duodenum;  but  this  must  be 
demonstrated  as  a  fact  before  beginning  the  feeding.  The  indications 
that  the  cai)sule  is  in  the  duodenum  are,  (1)  that  the  tube  has  passed 
to  the  third  mark;  (2)  gentle  traction  on  the  tube  develops  a  sense  of 
greater  resistance  than  if  the  capsule  were  lying  free  in  the  stomach; 
(3)  aspiration  removes  a  golden-yellow  duodenal  juice;  and  (4)  water 
given  by  mouth  cannot  be  aspirated  through  the  tube. 

The  food  injected  consists  of  milk,  sugar  of  milk,  and  raw  eggs,  in 
the  ])roportion  of  one  glass  of  milk,  one  egg,  and  a  tablespoonful  of 
sugar  of  milk.  The  amount  at  first  injection  is  100  c.c.  every  two 
hours,  from  7  a.m.  to  9  p.m.,  increasing  gradually  so  that  280  to  300 
c.c.  are  given  at  each  feeding,  representing  approximately  2800  calories. 
The  food  mixture  should  be  gradually  heated  so  as  to  avoid  lumpiness 
from  the  coagulation  of  the  egg,  and  then  strained.  The  food  should 
be  gi\en  at  body  temperature,  and  should  enter  the  duodenum  slowly. 
I'aihirc  in  cither  particular  will  cause  flatulence  and  distress. 

l'>inh(jrn  uses  a  glass  syringe  for  injection.  William  (icrry  Morgan 
uses  a  glass  irrigating  jar,  setting  the  petcock  so  that  the  nourishment 
flows  in  twenty-five  miimtes.  At  the  termination  of  each  feeding  a 
syringeful  of  water  should  be  injected  at  body  temperature,  the 
petcock  closed,  the  syringe  filled  with  air,  the  petcock  opened  and  air 
injected,   after  which   the  petcock   should   be  closed   and   the   syringe 


TREATMENT  189 

(iisconnected.  This  procedure  keeps  the  tul)e  clean  and  ck'ar.  These 
details  should  never  be  neglected. 

It  is  claimed  by  those  who  have  used  this  method,  that  nourishment 
can  be  given  sufficient  to  maintain  body  strength  and  weight,  and 
that  the  freedom  from  irritation  and  gastric  secretion  allow  of  the 
ready  healing  of  ulcer.  The  writer's  experience  with  duodenal  alimen- 
tation has  been  quite  limited,  as  he  has  found  that  the  majority  of 
patients  do  not  readily  accustom  themselves  to  the  constant  presence 
of  the  tube,  and  that  flatulence  and  distress  are  frequently  occasioned, 
in  s})ite  of  every  care  in  the  preparation  and  injection  of  the  nourish- 
ment. Whether  the  end-results  of  the  duodenal  alimentation  are 
superior  to  those  of  the  other  forms  of  treatment  cannot  be  decided 
at  present,  as  not  sufficient  time  has  elapsed  for  the  final  end-results 
to  be  tabulated. 

Indications  for  Surgical  Treatment. — During  the  past  few  years,  the 
relative  indications  for  medical  and  surgical  treatment  of  ulcer  have 
been  fully  and  freely  discussed,  with  the  result  that  at  the  present 
time  physicians  and  surgeons  have  come  to  think  and  act  in  perfect 
harmony  with  each  other.  There  is  no  such  thing  as  an  exclusive 
medical  treatment,  nor  can  it  be  affirmed  that  ulcer  is  a  purely  surgical 
disease — but,  on  the  other  hand,  while  some  ulcers  are  to  be  treated 
medically,  and  others  with  their  complications  call  imperatively  for 
surgical  treatment,  the  majority  are  grouped  near  the  borderline.  In 
these  doubtful  cases  the  main  indication  for  surgery  is  the  failure  of  a 
previous  medical  treatment  to  obtain  .beneficial  or  lasting  results. 

Acute  Uncomplicated  Ulcers. — Acute  uncomplicated  ulcers  are  best 
treated  medically.  This  is  conceded  by  all  surgeons  who  often  desig- 
nate this  form  as  "medical  ulcer."  Relief  by  medical  means  is  usually 
prompt  and  lasting. 

Chronic  Uncomplicated  Ulcers. — Chronic  uncomplicated  ulcer  should 
not  be  regarded  as  surgical  until  after  a  rigid  and  systematic  course  of 
medical  treatment,  the  symptoms  persist  or  recur.  It  must  be  empha- 
sized that  the  treatment  should  be  thorough,  and  continued  for  a 
sufficient  length  of  time,  as  medical  failures  are  due  more  often  to  half- 
hearted and  insufficient  treatment  than  to  actual  limitations  of  the 
healing  art.  In  general  terms  it  may  be  said  that  ulcers  that  do  not 
yield  to  two  months'  active  treatment  will  prove  resistant  except  to 
surgical  procedures.  Some  consideration  must,  however,  be  paid 
to  outside  conditions,  such  as  the  amount  of  time  that  can  be  given 
to  treatment,  or  the  probability  of  the  patient  taking  sufficient  care 
of  himself  during  the  convalescent  period,  to  prevent  relapse  or  recru- 
descences. In  the  case  of  a  laboring  man  whose  family  is  dependent 
upon  his  daily  wage  for  the  necessities  of  existence,  and  who  is   apt 


190  ACUTE  AND  CHRONIC  ULCER 

on  leaving  the  hospital  to  disregard  all  dietetic  rules  and  conventions, 
it  may  be  better  to  recommend  surgical  intervention  earlier  than 
would  be  advisable  in  the  case  of  those  whose  intelligence  and  environ- 
ment allow  of  a  conscientious  observance  of  the  details  of  treatment. 

If  after  a  vigorous  medical  treatment  the  symptoms  persist,  or  if 
in  spite  of  every  precaution  there  should  be  relapses,  indicating  that 
the  healing  of  the  ulcer  has  not  been  complete,  surgical  treatment  is 
indicated.  The  mortality  rate  and  the  percentage  of  cures  are  both 
on  the  side  of  surgery  in  these  cases. 

Exploration  is  demanded  without  loss  of  time  in  all  cases  in  which 
there  is  a  suspicion  of  malignancy. 

Single  Large  Hemorrhages. — Single  large  hemorrhages  are  best  treated 
medically.  If  the  bleeding  ceases  by  medical  means  no  harm  is  done, 
while  the  operation  of  opening  the  stomach  and  ligating  the  bleeding 
point,  when  perforated  during  a  period  of  acute  anemia,  is  extremely 
hazardous.  Hemoglobin  tests  under  35  per  cent,  contra-indicate 
operation  except  in  emergencies  in  which  great  risks  may  be  taken. 
On  the  other  hand,  hematemesis  that  ceases  spontaneously  is  often 
accompanied  by  anemia  even  greater  than  this. 

Recurring  Hemorrhages. — Recurring  hemorrhages,  if  not  relieved  by 
a  course  of  medical  treatment,  may  properly  be  placed  on  the  surgical 
list,  especially  if  the  continued  loss  of  blood  occasion  a  progressive 
anemia.  In  these  cases  operation  should  not  be  too  long  deferred,  as 
there  may  be  complicating  malignancy  present.  Cases  in  which 
occult  bleeding  follows  every  attempt  to  place  the  patient  upon  solid 
food,  after  a  regular  ulcer  treatment,  should  invite  surgical  intervention. 

Perforation. — Perforation,  either  acute,  subacute,  or  chronic,  is  a 
purely  surgical  complication.  Acute  perforations  demand  instant 
operation,  as  every  hour  that  elapses  until  the  aperture  is  c  osed 
diminishes  the  patient's  chance  of  recovery.  Immediate  laparotomy 
is  called  for  alike  in  those  cases  with  but  slight  amount  of  initial  shock, 
such  as  are  often  encountered  with  duodenal  perforations,  and  those 
in  whom  initial  shock  is  profound.  It  would  be  a  fatal  error  in  judgment 
to  temporize  in  the  one  case  until  the  indications  for  interference 
become  more  manifest,  or  to  defer  laparotomy  on  the  other  in  the  hope 
of  bringing  the  patient  into  a  better  physical  condition  to  withstand 
an  opcnitioii. 

Obstruction  and  Adhesions.  Pyloric  obstruction,  hour-glass  contrac- 
tions of  the  stomach,  or  persistent  adhesions  which  interfere  with  the 
proper  drainage  of  the  stomach  into  the  })owel  are  to  be  treated 
surgically,  although  in  the  majority  of  instances  preliminary  treat- 
ment by  lavage  and  diet  may  so  improNc  the  general  condition  that 
the  operation  is  performed  witii  a  minimum  risk. 


TREATMENT  191 

Adhesions  whose  presence  is  only  to  })e  surmised  and  which  do  not 
interfere  with  the  proper  motiHty  of  the  stomach  are  best  left  untreated. 
An  exception  may  be  made  in  those  perigastric  adhesions,  especially 
those  usually  between  the  lesser  curvature  of  the  stomach  and  the 
under  surface  of  the  liver,  which  are  dragged  upon  by  physical  exer- 
tions, or  even  during  locomotion,  and  give  rise  to  such  discomfort  as 
to  render  it  impossible  for  the  patient  to  be  up  and  about  doing  his 
work. 


CHAPTER   V 

p:rosions  and  rare  ulcers 

HEMORRHAGIC   EROSIONS 

The  term  hemorrhaji;ic  erosions  indicates  those  minute  ulcers  of  the 
stomach,  single  or  multiple,  which  invade  only  the  more  superficial 
portion  of  the  gastric  mucous  membrane  and  which  heal  completely, 
leaving  no  trace  of  any  loss  of  continuity  whatever.  PathologicaJly 
they  are  ulcers,  but  it  is  convenient  to  describe  them  under  a  separate 
heading  as  their  clinical  course  is  somewhat  different  from  the  deeper 
erosions  ordinarily  described  as  gastric  or  duodenal  ulcers. 

It  is  a  dis])uted  question  whether  erosions  and  ulcers  represent  two 
distinct  ulcerative  processes  or  whether  an  ulcer  is  not  merely  a  well- 
developed  and  more  extensive  erosion.  Those  who,  affirm  that  the 
erosion  is  merely  a  small  shallow  ulcer  which  may  extend  in  depth 
and  persist  as  the  classical  ulcer,  base  their  conclusions  on  the  finding 
at  post  mortem  of  multiple  superficial  erosions  and  well-developed 
ulcerations  in  adjacent  portions  of  the  same  stomach.  This  is  the 
view  held  by  (Jerbardt,^  Nauwerk,^  and  Dieulafoy,  and  in  this  opinion 
the  writer  is  inclined  to  coincide  and  to  believe  that  the  subdivision 
of  ulcer  from  erosion  is  useful  for  purely  clinical  reasons  rather  than 
because  there  is  any  essential  dift'erence  in  the  pathology  of  these  two 
kindred  conditions. 

Whatever  way,  however,  this  ([uestion  is  answered,  one  fact  remains 
undisputed,  namely,  the  passage  from  a  shallow  erosion  to  the  typical 
deeper  ulcer  is  one  of  great  rarity.  Erosions  may  appear  both  in  an 
acute  and  in  a  chronic  form. 

Acute  Hemorrhagic  Erosions. — The  formation  of  hemorrhagic 
erosions  as  the  name  implies,  consists  of  two  stages.  In  the  first  stage 
there  occur  large  or  small  multiple  hemorrhages  into  the  substance  of 
the  mucous  membrane,  appearing  as  purplish  brownish  or  black  patches, 
which  later  become  digested,  leaving  superficial  ulcers.  Such  resulting 
erosions  may  be  solitary  or  multiple.  The  size  varies  from  minute 
pore-like  excavations  to  broad  shallow  depressions,  as  if  the  surface 

'  \'irch.  Arch.,  cxxvii,  M.5. 

-  .MiiiKh.  I1H-.1.  Woch.,  1895,  p.  38  and  39;  1897,  p.  35  and  36. 


HEMORRHAGIC  EROSIONS 

Fig.  32 


193 


Hemorrhagic  erosion  of  stomach.     The  area  of  hemorrhage  is  well  seen  at  .4. ;  the  superficial  loss 
of  substance  at  B.     (From  the  Pathological  Museum  of  the  Mt.  Sinai  Hospital,  New  York.) 


/ 


Multiple  hemorrhagic  erosions  of  stomach.     Many  of  these  hemorrhagic  areas  can  be  seen  as  at 
A,  A,  A.     Several  pieces  of  the  stomach,  as  at  X,  X,  have   been    removed  for  microscopical  examina- 
tion.     (From  the  Pathological  Museum,  Mt.  Sinai  Hospital,  New  York.) 
13 


194  •     EROSIONS  AND  RARE   ULCERS 

of  the  membrane  had  been  lightly  brushed  off  with  the  fingers.  They 
may  be  extremely  difficult  to  find  at  post  mortem  or  in  the  living 
stomach  at  operation,  and  may  even  totally  elude  the  most  careful 
search.  Postmortem  digestion  rapidly  effaces  these  very  superficial 
ulcerations.  Although  they  do  not  invade  the  muscularis,  erosions  of 
small  arteries  may  occur,  which  may  result  in  serious  or  even  fatal 
hemorrhage.  As  distinguished  from  the  ordinary  forms  of  ulcer,  they 
tend  to  heal  rapidly  and  completely,  leaving  no  trace  behind  as 
evidence  of  their  existence. 

In  many  cases  similar  erosions  are  found  in  the  duodenum  and 
jejunum,  and  there  are  often  subperitoneal  hemorrhages. 

Etiology. — Gastric  erosions  may  form  as  the  result  of  any  one  of 
three  distinct  conditions. 

Toxic. — The  fact  seems  well  established  that  in  many  septic  condi- 
tions bacteria  may  either  invade  the  membrane  of  the  stomach  and 
cause  small  areas  of  necroses,  or  toxins,  circulating  in  the  blood  may  act 
as  endothelial  poisons  on  the  wall  of  the  arterioles  and  thus  allow  the 
escape  of  blood  into  the  tissues.  A  very  good  illustration  of  the  type 
of  direct  bacterial  invasion  is  given  us  by  Dieulafoy  in  his  description 
of  pneumococcal  gastritis  with  ulceration. 

His  patient  was  admitted  to  the  hospital  with  pneumonia ;  abdominal 
pain,  tympanites,  vomiting,  and  diarrhea  were  present.  The  day  of 
the  admission  he  vomited  a  pint  and  a  half  of  blackish  fluid-like 
coffee  grounds  and  the  stools  contained  blood.  Death  occurred  on 
the  following  day. 

Postmortem  examination  showed  pneumococcic  infection  of  the 
lung,  pleura,  pericardium,  and  peritoneum.  There  were  erosions  in  the 
mucous  membrane  of  the  stomach,  multiple  and  exceedingly  minute, 
and  in  the  interglandular  stroma  around  the  edges  of  these  erosions 
were  pure  cultures  of  the  pneumococcus. 

A  further  proof  that  erosions  may  be  due  to  direct  deposition  of  bac- 
terial organisms  in  the  tissues  is  afforded  by  the  fact  that  in  many 
instances  small  miliary  abscesses  of  the  mucous  membrane  are  found 
associated  with  the  erosions.  In  a  case  of  Giraudeau's,  reported  by 
Dieulafoy,  the  ulceration  involved  an  arterial  branch  and  in  the  neigh- 
})()rii<)od  of  the  vessel  masses  of  leukocytes  were  seen  representing  true 
miliary  abscesses,  with  numberless  microorganisms  in  chains. 

It  has  been  long  surmised  that  toxins  of  many  kinds  may  be  the  cause 
for  multiple  erosions  of  the  stomach.  This  mode  of  origin  seems  quite 
definite  in  the  case  of  uremic  ulcerations  and  the  duodenal  ulcerations 
that  complicate  burns  of  the  surface  of  the  Ixxly.  Although  definite 
proof  is  lacking,  it  would  seem  that  poisons  formed  from  the  pent-up 
secretions   in    appendicitis  or  gall-bladder  infections  were  capable  of 


HEMORRHAGIC  EROSION,S  195 

assuming  the  role  of  gastrotoxins  and  of  producing  definite  gastric 
lesions.  There  is  no  doubt  that  gastric  erosions  occur  frequently  enough 
with  infections  of  the  appendix  and  gall-bladder,  but  whether  due  to  the 
elaboration  of  endotoxins  or  to  pyloropasm  with  attending  traumatism 
of  the  mucous  membrane  of  the  pyloric  antrum  is  not  always  a  question 
of  easy  solution.  Toxic  erosions  of  the  gastric  mucosa  is  the  usual 
cause  for  the  gastric  hemorrhages  that  accompany  a  splenic  anemia 
and  certain  disorganized  states  of  the  blood. 

Retrograde  Embolism. — It  is  supposed  that  in  some  instances  retro- 
grade embolism  from  detached  thrombi,  may  be  the  cause  for  the 
lesion,  the  thrombi  being  formed  in  the  ligated  veins  of  the  mesentery 
or  omentum. 

This  is  the  view  held  by  von  Eiselberg  to  explain  postoperative 
hematemesis  of  the  abdominal  operations,  but  it  seems  doubtful  if 
it  will  explain  more  than  a  very  small  minority  of  such  cases. 

Muscular  Contractions  and  Pylorospasm. — It  is  possible  that  mus  ular 
contraction  of  the  pyloric  end  of  the  stomach  and  pylorospasm  induced 
by  irritative  lesions  in  the  embryological  midgut  or  its  derivatives 
may  inflict  sufficient  traumatism  upon  the  mucous  membrane  of  that 
portion  of  the  stomach  as  to  devitalize  certain  areas  of  it  and  allow  of 
autodigestion.  This  mode  of  origin  of  erosion  would  explain  the  largest 
number  of  cases  which  occur  as  complications  of  gall-bladder  or  infec- 
tions, and  of  both  acute  and  chronic  complications  of  the  appendix. 
That  such  a  muscular  spasm  does  occur  is  well  established,  both  by 
the  .T-ray  and  by  the  presence  of  visible  contractions  at  the  time  of 
operations  done  for  the  relief  of  chronic  appendicitis  or  the  gall-bladder 
disease. 

Symptoms. — Before  the  predominant  symptoms  of  hemorrhage  occur 
the  patient  may  complain  of  more  or  less  pain  in  the  region  of  the 
stomach  and  the  raising  of  acid  fluid  which  may  contain  blood.  A 
disagreeable  taste  in  the  mouth  that  is  quite  unlike  that  common  to 
the  ordinary  type  of  indigestion  may  be  a  noticeable  factor,  and  may 
seriously  interfere  with  the  appetite  of  the  patient.  When  blood  is 
finally  vomited,  its  taste  then  appears  to  be  identical  with  that  com- 
plained of  before  the  actual  emesis.  During  this  time  the  patient  may 
have  a  peculiarly  ill  appearance,  and  is  often  of  an  ashy  paleness. 
These  symptoms  occurring  in  a  patient  who  has  had  an  abdominal 
operation  should  excite  suspicion,  and  examinations  of  the  stools 
should  at  once  be  made  for  occult  blood.  These  symptoms  are  apt 
to  occur  within  three  days  after  operation. 

The  most  prominent  symptom  of  erosion  is  hemorrhage,  either  a 
single  large  hemorrhage  or  smaller  hemorrhages  frequently  repeated 
and  associated  with  melena.     In  the  majority  of  instances  a  profuse 


190  EROSIONS  AND  RARE   ULCERS 

and  lightning-like  hematemesis  is  the  first  indication  of  the  illness, 
and  may  be  so  severe  that  death  results  from  acute  anemia  during 
the  first  attack. 

Subsequent  hemorrhages  are  not  infrequent.  In  those  cases  which 
have  been  operated  on  for  the  relief  of  hemorrhage  or  which  have  gone 
to  post  mortem  it  has  often  been  well-nigh  impossible  to  find  the  point 
or  points  from  which  the  hemorrhage  has  taken  place.  In  many  in- 
stances the  bleeding  has  occurred  from  numerous  points,  so  that  it 
has  been  said  that  the  mucous  membrane  weeps  blood.  These  obscure 
cases  in  hemorrhage  have  been  termed  by  Hale  White,  "  Gastrostaxis" 
or  the  bleeding  from  a  stomach  which  shows  no  visible  ulcer,  but 
whether  or  not  such  cases  really  occur  without  ulceration  or  erosion 
may  be  doubted.  It  seems  most  probable  to  the  writer  that  these  are 
merely  cases  in  which  the  bleeding-points  are  not  found  owing  to 
their  minuteness. 

It  has  often  happened  that  a  cause  for  gastric  oozing  has  not  been 
found  by  the  one  observer,  although  minute,  pore-like  erosions  account- 
able for  the  hemorrhage  have  been  demonstrated  by  a  subsequent 
examination  of  the  same  specimen. 

Fenwick^  says  that  in  one  instance  he  was  able  to  demonstrate  by 
artificial  injection  the  source  of  a  fatal  hemorrhage  that  had  eluded 
the  most  careful  search  at  the  necropsy. 

Prognosis. — The  prognosis  is  usually  good,  as  the  erosions  ordinarily 
heal  rapidly  and  are  not  followed  by  the  symptoms  of  chronic  ulcera- 
tion. Even  in  cases  in  which  anemia  is  extreme  and  threatening, 
recovery  may  be  hoped  for.  In  two  cases  reported  by  Dieulafoy  the 
patient  made  a  satisfactory  recovery  after  a  blood  count  of  only  030,000. 
When,  however,  hemorrhages  are  associated  with  severe  general  infec- 
tions, the  prognosis  is  exceedingly  grave. 

Treatment. — The  most  clean-cut  and  definite  point  of  the  treatment 
is  that  the  cases  are  to  be  treated  on  purely  medical  lines;  with  acute 
hemorrhages  or  erosions  surgery  has  nothing  whatever  to  do.  The 
medical  treatment  is  that  of  acute  ulcer. 

Conditions  of  extreme  anemia  may  require  hypodermoclysis  or  the 
infusion  of  salines  by  the  Murphy  drip.  In  urgent  cases  direct  trans- 
fusion of  blood  as  an  emergency  operation  may  be  advisable.  Adrenalin 
may  or  may  not  be  of  service.  Calcium  salts  and  solution  of  gelatin 
have  been  disa})pointing  in  their  results.  The  hypodermic  use  of  rabbit 
or  horse  serum  has  been  recommended,  and  the  writer  has  seen  cases  in 
which  such  a  serum  treatment  has  apparently  been  of  use  in  controlling 
the  loss  of  blood. 

1  Lancet,  March  12,  1010, 


HEMORRHAGIC  EROSIONS  197 

Chronic  Hemorrhagic  Erosions.  This  term  is  used  to  describe  the 
condition  in  which  bits  of  mucous  membrane  are  found  in  the  lavage 
water  of  the  fasting  state,  usually  associated  with  chronic  gastritis  or 
achylia,  and  characterized  clinically  by  epigastric  pain  after  meals. 
This  condition  has  been  fully  described  by  Einhorn,  Sansoni,  and  Quin- 
tard,  and  by  these  writers  is  considered  to  be  a  clinical  entity.  The 
characteristic  features  of  the  ailment  appear  to  be  the  finding  of  small 
fragments  of  mucous  membrane  occurring  quite  constantly  in  the  return 
flow  of  the  stomach  washings  in  the  fasting  state.  Pain  is  a  fairly 
constant  symptom  usually  occurring  soon  after  meals,  attaining  its 
height  within  a  moderate  time  and  then  gra  ually  dis  ppearing  as  the 
stomach  empties  itself.  The  pain,  according  to  some  writers,  may  be 
exceedingly  severe,  according  to  others,  quite  insignificant,  constituting 
a  feeling  of  distress  rather  than  a  true  pain.  Bleeding  may  occur  and 
is  usually  of  the  occult  type.  Sansoni  has,  however,  noted  well-marked 
hemorrhages  in  several  of  his  patients.  It  is  said  that  the  diagnosis 
should  be  suspected  whenever  symptoms  of  ulcer,  such  as  pain  and 
hemorrhage,  are  complained  by  a  patient  who  is  suffering  from  chronic 
gastritis  or  achylia. 

The  writer  believes  that  chronic  hemorrhagic  erosions  thus  described 
do  not  occur  as  a  distinct  clinical  entity.  It  is  a  well-known  fact  that 
the  mucous  membrane  in  achylia  is  particularly  friable,  so  that  in  taking 
the  test  breakfast  we  find  pieces  of  mucous  membrane,  often  of  con- 
siderable size,  in  the  eye  of  the  tube.  The  evulsion  of  such  pieces  is 
not  followed  by  any  unpleasant  results.  A  similar  experience  often 
occurs  with  the  passage  of  the  tube  in  chronic  gastritis.  The  writer 
would  therefore  regard  this  form  of  hemorrhagic  erosion  as  an  artefact 
and  one  that  becomes  more  and  more  rare  the  more  carefully  we  select 
a  tube  whose  apertures  are  soft  and  rounded.  As  to  pain  in  achylia 
being  due  to  hemorrhagic  erosions,  it  would  be  interesting  to  know 
in  how  many  of  these  patients  the  pain  was  due  to  gall-bladder  or 
appendicular  disease. 

A  history  of  one  of  the  writer's  patients  was  at  one  time  considered 
by  him  typical  of  hemorrhagic  erosions,  the  so-called  "  gastritis  anacida 
ulcerosa"  of  Sansoni,  until  the  patient  was  operated  upon  for  chronic 
appendicitis,  after  which  all  pain  and  gastric  discomfort  disappeared. 

Mrs.  A.  C,  aged  thirty  years,  was  well  until  five  years  ago  when 
without  apparent  cause  she  began  from  time  to  time  to  suft'er  from 
nausea  and  vomiting.  Four  years  ago  there  was  added  a  pain  which 
started  in  the  epigastrium  and  thence  downward  and  to  the  back, 
coming  shortly  after  eating  and  gradually  wearing  away.  Nausea 
and  vomiting  might  accompany  the  acme  of  pain.  There  would  be 
intervals  of  time  during  which  she  was  free  from  all  symptoms. 


198  EROSIONS  AND  HARE   ULCERS 

Physical  examination  showed  slight  tenderness  over  McBurney's 
point,  a  moderate  degree  of  gastroptosis  was  present,  gall-bladder  neither 
palpable  or  tender.  Gastric  analysis  showed  chronic  mucous  gastritis 
of  the  achylia  type.  On  washing  the  stomach  bits  of  mucous  membrane, 
averaging  the  size  of  the  head  of  a  pin,  with  on  one  occasion  a  moderate 
amount  of  blood,  were  fairly  constantly  found.  She  was  treated  by 
la\'age  with  1000  to  3000  silver  nitrate,  and  by  an  ulcer  diet  without 
much  success  until  the  appendix  was  removed,  after  which  she  was 
perfectly  well  without  return  of  her  stomach  symptoms. 

The  writer  does  not  wish  to  make  the  positive  statement  that  this 
form  of  exfoliating  erosions  does  not  exist,  but  would  regard  the  ques- 
tion of  its  clinical  entity  as  not  proved,  or  even  probable  at  the  present 
time. 


JEJUNAL    AND    GASTROJEJUNAL    ULCERS    FOLLOWING 
GASTROJEJUNOSTOMY 

Ulceration  of  the  jejunum  near  the  site  of  the  anastomosis  that  is 
made  in  the  operation  of  gastrojejunostomy  has  been,  considered  one 
of  the  dangers  that  may  follow  such  an  operation. 

According  to  Paterson^  we  are  justified  in  estimating  the  probable 
risk  of  jejunal  ulcer  following  gastrojejunostomy  at  a  little  under  2 
per  cent.  It  is,  however,  a  question  whether  this  form  of  ulcer  is  as 
common  today,  with  improved  methods  of  technique,  as  it  was  in  the 
early  days  of  gastric  surgery.  Nevertheless  of  72  consecutive  cases 
of  gastrojejunostomy  done  for  the  relief  of  gastric  or  duodenal  ulcer 
recently  reported  by  Sherren,^  jejunal  ulcer  complicated  the  convales- 
cence in  two  instances.  Both  occurred  after  the  posterior  no-loop 
operation,  von  Roojen  reports  3  cases  of  peptic  jejunal  ulcer  in  which 
no  operation  had  previously  been  done. 

Mayo^  writes  that  of  1141  gastrojejunostomies  up  to  December  31, 
1909,  by  himself  and  brother,  C.  H.  Mayo,  in  not  a  single  instance  did 
true  jejunal  ulcer  occur,  nor  had  any  such  cases  come  to  his  clinic  ia 
which  gastrojejunostomy  had  been  performed  by  other  surgeons. 
Mayo,  however,  makes  a  difference  between  ulcers  that  are  implanted 
at  the  site  of  the  anastomosis  and  the  true  jejunal  ulcers  that  occur 
in  the  jejunum  itself  without  involving  the  anastomotic  ring. 

Paterson  estimates  that  in  nearly  one-third  of  the  recorded  cases 
the  ulcer  was  probably  gastric  rather  than  jejunal,  and   in  all  prob- 

»  Annals  of  Surgery,  August,  1909.  ^  Lancet,  July  13,  1912,  p.  76. 

'  Surgery,  Gynecology,  and  Obstetrics,  March,  1910. 


JEJUNAL  AND  G  ASTRO  JEJUNAL   ULCERS  199 

ability  originated  in  the  gastric  mucous  membrane  surrounding  the 
anastomotic  opening.  For  ulcers  at  the  site  of  the  anastomosis  he 
suggests  the  terms  "gastrojejunal"  to  differentiate  them  from  the 
ulcers  which  occur  in  the  jejunal  loops,  the  "jejunal  ulcer"  proper. 
-The  writer  adopts  this  subdivision  of  postoperative  ulcerations  into 
these  two  groups. 

Jejunal  Ulcers. — It  is  curious  that  males  are  more  affected  than  females 
with  this  disorder,  either  because  men  are  more  indiscreet  in  their 
diet  than  are  women,  especially  in  the  use  of  alcohol  after  operations, 
or  because,  as  Paterson  suggests,  more  gastrojejunostomies  are  done 
in  men  than  in  women.  Of  50  cases  reported  by  Paterson  in  which  the 
sex  of  the  patient  was  mentioned,  a  proportion  of  78  per  cent,  of  men 
is  recorded.  Schostak^  found  32  males  were  affected  in  a  series  of 
35  cases.  The  complication  has  occurred  after  nearly  all  the  varia- 
tions of  the  operation,  but  seems  to  be  less  frequent  with  the  modern 
short  loop  than  in  the  older  method  in  which  a  long  loop  pf  the  jejunum 
was  used  for  the  anastomosis. 

Pathology. — The  ulcer  may  occur  in  the  jejunum  near  the  anas- 
tomosis, rarely  at  a  point  farther  than  6  or  7  c.c.  from  the  stoma.  A 
single  ulcer  is  the  rule,  although  several  ulcers  have  been  found  grouped 
together. 

In  some  instances  there  is  marked  dilatation  of  the  afferent  loop, 
occasionally  of  both  the  afferent  and  efferent  loop.  In  a  case  reported 
by  Percy^  both  loops  were  enlarged  to  an  external  diameter  of  2|  inches. 
Their  walls  were  stiff  and  thick,  and  without  the  collapsible  feeling 
normal  to  the  small  intestine. 

Such  an  ulcer  may  perforate  with  or  without  limiting  adhesions, 
so  that  general  peritonitis  or  a  localized  peritoneal  abscess  may  ensue. 
Adhesions  may  form  with  the  neighboring  parts,  especially  the  anterior 
abdominal  wall  and  the  transverse  colon,  and  by  extension  of  the 
necrotic  process  fistulas  may  form.  The  microscopical  pathology  is 
identical  with  that  of  gastric  and  duodenal  ulcer. 

Etiology. — The  most  potent  cause  in  the  formation  of  postoperative 
jejunal  ulcer  is  the  passage  of  hyperacid  gastric  juice  into  a  part  of  the 
intestine  which  is  not  naturally  resistant  as  is  the  duodenum  to  its 
erosive  action.  Katsenstein's  experiments  on  autodigestion  are  inter- 
esting. He  has  proved  that  the  introduction  of  the  normal  duodenum 
into  a  living  stomach  of  the  same  animal  is  unattended  by  an  erosive 
action  on  the  loop  so  introduced,  but  that  introduction  of  a  loop  of 
jejunum  under  the  same  conditions  is  followed  by  its  total  erosion. 

1  Beitriige  z.  klin.  Chir.,  1907,  Ivi,  360. 

2  Jour.  Amer.  Med.  Assoc,  April  9,  1910. 


200  EROSIONS  AND   RARE    ULCERS 

His  argument  is  that  those  tissues  which  produce,  or  are  normally 
bathed  in  gastric  juice,  are  ordinarily  immune  from  its  eroding  effect, 
but  that  all  other  tissues  succumb  to  the  digesting  power  of  this  fluid 
when  immersed  in  it  in  the  living  state. 

Hyperacidity  was  present  in  13  out  of  the  18  cases  recorded  by  Pat- 
erson  in  which  the  gastric  analysis  were  made.  Hyperchlorhydria 
occurred  in  17  out  of  21  cases  reported  by  Mayo  Robson.  It  is  im- 
portant however,  to  remember  that  it  may  not  be  the  hyperacidity 
alone,  but  the  continuous  flow  of  gastric  juice,  the  hypersecretion  so 
commonly  o})served  in  these  instances,  which  supplies  the  corroding 
agent. 

This  hypothesis  though  plausible  is  insufficient  to  explain  all  the 
cases  thus  far  observed.  If  hyperacidity  were  the  potent  factor  in 
inducing  jejunal  ulcers  which  we  suppose  it  to  be,  it  is  more  probable 
that  the  symptoms  of  ulceration  would  appear  soon  after  the  operation, 
especially  if  we  believe  that  traumatism  of  the  jejunal  wall  is  a  con- 
tributing cause  for  such  an  ulceration.  It  is  the  late  cases,  those  which 
occur  two,  three,  or  more  years  after  the  operation,  that  are  difficult 
to  explain. 

It  is  interesting  in  this  connection  to  note  that  but  one  case  of  jejunal 
ulcer  has  followed  gastro-enterostomy  for  carcinoma  of  the  stomach. 
(Lennander.)  It  may  so  be  that  other  factors  other  than  hyperacidity 
tend  in  exceptional  cases  to  produce  the  condition. 

1.  It  is  observed  by  some  that  a  contraction  of  the  jejunum  below 
the  anastomosis  may  occur,  allowing  stagnation  and  the  prolonged 
action  of  the  gastric  juice  on  the  mucous  membrane  of  the  jejunum 
above  this  point  of  constriction. 

2.  Traumatism  at  the  time  of  the  operation  may  so  injure  the  wall 
of  the  gut  as  to  allow  the  devitalized  area  to  become  an  easy  prey  to 
peptic  digestion. 

3.  The  normal  circulatory  conditions  may  be  so  disturbed  by  the 
abnormal  position  and  fixation  of  the  loops  that  form  the  anastomosis, 
that  areas  of  local  anemia  may  occur,  favoring  the  formation  of  ulcers. 
Thus  the  loo])  of  the  jejunum  which  passes  in  front  of  the  transverse 
colon  may  be  insufficient  in  length,  so  that  it  may  become  subject  to 
tension,  or  by  kinks  in  the  mesentery  itself  its  blood  supply  may  be 
impeded. 

4.  In  a  few  ca.ses  jejunal  ulcers  arc  probably  of  infective  origin  as 
they  occur  within  a  short  period  after  gastrojejunostomy,  and  are 
usually  multiple.     The  exact  nature  of  the  toxin  is  unknown. 

Paterson  represents  .schematically  the  etiology  of  jejunal  ulcer  as 
follows: 


JEJUNAL  AND  (JASTROJEJ CNAL   ULCERS 


201 


Scheme  of  Causks  of  Jbjunal  Ui.ceii 
Hyperacidity,  noriiial  flow  of 
l)il(",  and  |)anr;rpati(;  juice 

Normal  acidit}-,  but  hyper-  i 
secretion,  normal  flow  ot"  bile,  '' 
etc.  J 

Normal  acidity,  diminished  | 
flow,  or  diversion  of  bile,  etc.       / 

Normal  acidity,  normal  flow 
of  bile,  etc.;  toxic  agent  other 
than  hj'drochloric  acid 

Infective  processes 


Jejunal  ulcer 


Fig.  34 


Ulcer   of  Duodenura 


Qastro- le  I V  rval  Ulcer 
Gastrojejunal  ulcer,  the  result  of  infected  hematoma.      (Mayo.) 

Gastrojejunal  Ulcers. — Gastrojejunal  ulcers,  or  ulcers  occurring  at 
the  anastomotic  ring,  are  not  infrequently  observed.  Hitherto  they 
have  been  included  under  the  general  term  of  jejunal  ulcers.     A  true 


202  EROSIONS  AND  RARE  ULCERS 

jejunal  ulcer  is  rather  an  unavoidable  condition,  but  the  gastrojejunal 
ulcers  are  probably  due  to  technical  failure  in  the  operation  itself. 
In  1141  gastrojejunostomies  done  by  W.  J.  Mayo  and  C.  H.  Mayo, 
three  such  cases  are  reported :  the  first  being  the  result  of  the  impaction 
of  a  Murphy  button,  producing  a  pressure  ulcer;  the  second  case  occurred 
as  the  result  of  retention  of  infected  suture  material;  the  third  was 
due  to  infected  hematoma  in  the  suture  line.  The  ulcer  may  be  at  any 
portion  of  the  anastomotic  ring,  or  may  completely  surround  it. 

Symptoms  of  Jejunal  and  Gastric  Jejunal  Ulcer. — Jejunal  ulcers  may, 
like  those  of  the  stomach  or  duodenum,  run  an  entirely  symptomless 
course  until  they  perforate.  How  many  ulcers  there  are  which  run 
a  latent  course  and  which  heal  without  ever  giving  the  least  evidence 
of  their  presence  we  have  no  idea,  but  a  review  of  the  cases  collected 
by  Paterson  leads  us  to  the  belief  that  a  diagnosis  is  made  only  when 
perforation  or  other  untoward  complications  arise.  There  must  be 
an  even  larger  group  which  give  symptoms  so  insignificant  that  the 
occurrence  of  the  ulcer  is  unsuspected,  or  whose  clinical  course  is  such 
that  the  diagnosis  can  only  be  considered  possible  or  even  probable. 

The  period  of  time  between  the  original  gastrojejunostomy  and  the 
onset  of  symptoms  varies  considerably  as  is  shown  in  the  following 
table  of  Paterson's: 

Under  1  month 5  cases 

2  to  3  months 6  cases 

3  to  6  months 7  cases 

6  months  to  1  year 11  cases 

1  to  2  years 8  cases 

2  to  3  years 4  cases 

Over  3  years 8  cases 

Interval  not  stated 3  cases 

52  cases 

It  is  thus  seen  that  in  over  one-half  the  cases  the  symptoms  of  ulcer 
appear  within  a  year  and  in  three-quarters  of  the  cases  within  two 
years  after  the  operation.  The  shortest  interval  was  two  days,  the 
longest  eight  years,  while  the  average  in  all  the  cases  was  twenty- 
months. 

The  usual  history  is  that  after  a  certain  period  of  freedom  from  the 
symptoms  for  which  the  gastrojejunostomy  was  done,  the  patient 
will  begin  to  complain  again  of  epigastric  pain.  The  distress  is  usually 
greatest  two  to  four  hours  after  meals  and  is  not  relieved  as  a  rule 
by  eating,  but  gradually  wears  away.  Occasionally  large  doses  of  soda 
bring  relief.  The  quality  of  the  food  makes  no  apparent  difference 
in  the  severity  of  the  pain.    The  history  may  closely  resemble  or  may 


JEJUNAL  AND  GASTROJEJUNAL   ULCERS  203 

even  be  identical  with  that  prior  to  the  operation,  and  it  is  probable 
that  many  patients  who  complain  of  a  contimiance  or  a  recurrence 
of  their  old  ulcer  symptoms  after  operation  are  really  suftering  from 
a  gastrojejunal  or  jejunal  ulcer  subsequent  upon  the  surgical  event. 
The  pain,  however,  usually  lacks  the  clean-cut  definition  of  that  of 
gastric  or  duodenal  ulceration.  Gastric  analysis,  though  usually  show- 
ing hyperacidity,  is  not  noteworthy  in  any  other  regard,  save  that  the 
continual  presence  of  occult  blood  points  toward  an  ulceration  that 
may  involve  the  anastomotic  ring  or  either  loop  of  the  jejunum  near 
the  orifice,  and  this  surmise  is  strengthened  if  concomitant  reaction 
for  occult  blood  be  obtained  by  examination  of  the  stools.  Tenderness, 
if  present,  is  usually  elicited  in  the  median  line,  or  slightly  to  the  left 
between  the  navel  and  the  costal  arch.  The  reappearance  of  epigastric 
pain  or  distress  some  hours  after  the  taking  of  food  in  patients  in  whom 
gastrojejunostomy  has  brought  relief  from  their  original  symptoms  for 
some  months,  should  call  most  imperatively  for  close  observation, 
and  indicates  the  necessity  for  a  rigid  enforcement  of  a  medical  ulcer 
cure. 

With  or  without  an  antecedent  history  of  epigastric  distress,  obvious 
hemorrhage  may  occur  ordinarily  as  melena,  occasionally  associated 
with  hematemesis.  The  nearer  the  ulcer  is  to  the  orifice  and  the  more 
rapid  the  hemorrhage,  the  greater  is  the  tendency  for  the  blood  to  be 
both  vomited  and  passed  by  the  bowel.  Such  a  case  of  hemorrhage 
reported  by  W.  G.  Lyle,^  seen  in  consultation  by  the  writer,  may  be 
briefly  cited. 

W.  B.  D.,  Jr.,  aged  twenty-six  years.  Patient  was  well  until  eight 
years  ago,  when  he  developed  gnawing  pains  in  the  abdomen,  betw^een  the 
ensiform  and  umbilicus,  coming  three  or  four  hours  after  eating  and  last- 
ing until  he  ate  again.  The  more  he  ate  the  longer  the  period  of  relief. 
The  pain  continued  wdth  periods  or  remission  for  seven  years,  when  the 
ulcer  suddenly  perforated.  He  was  operated  upon,  and  a  perforated 
ulcer  the  size  of  a  ten-cent  piece  was  found  three-fourths  inch  from  the 
pylorus,  but  not  causing  stenosis.  After  suturing  the  perforation  a  pos- 
terior gastro-enterostomy  was  done,  and  an  entero-enterostomy  also 
performed  about  four  inches  below  the  site  of  the  gastro-enterostomy. 
Recovery  was  uneventful,  and  he  was  free  from  all  digestive  disturb- 
ances until  six  months  later,  when  there  was  a  return  of  his  abdominal 
pain,  with  a  series  of  black  tarry  stools.  These  symptoms  continued 
for  several  weeks.  Examination  of  the  stomach  showed  a  mild  hyper- 
secretion in  the  fasting  condition,  of  a  total  acidity  of  55,  free  HCl  30. 
Test  breakfast  showed  a  total  acidity  of  90,  free  HCl  60.     Stools  gave 

1  New  York  Med.  Jour.,  December  22,  1906,  p.  1230. 


204  EROSIOXS  AM)   RARE   ULCERS 

continuously  positixe  blood  reactions.  Patient  was  put  under  the  von 
Leube  treatment,  witli  belladonna  and  alkalies,  and  made  a  good  recov- 
ery, having  had  no  return  of  his  old  symi)toms  for  the  ])ast  three  years. 

In  certain  instances  of  probable  inplantment  of  the  ulcerous  process 
at  or  near  the  anastomotic  opening,  either  jejunal  or  gastrojejunal  in 
type,  there  occur  acute  exacerbations  of  more  or  less  constant  pain, 
with  nausea  and  the  vomiting  of  large  quantities  of  acid  fluid  which 
contain  food  remains  and  usually  traces  of  blood.  It  is  probable  that 
the  symptoms  arise  through  inflammatory  tumefaction  of  the  tissues 
forming  the  edges  of  the  artificial  opening  into  the  bowel  or  from 
recurring  ulcers  at  the  brim  of  the  stoma.  Between  the  attacks  the 
patient  may  feel  perfectly  well,  eat  with  impunity,  and  gain  what  he 
has  lost.  After  a  certain  number  of  the  attacks  permanent  recovery 
may  result. 

The  history  of  a  case  in  which  this  intermittent  course  occurred, 
eventuating  in  recovery,  is  as  follows: 

H.  T.  C,  aged  fifty-seven  years,  came  under  observation  April  27, 1902, 
with  obvious  pyloric  stenosis  and  food  stagnation.  Gastro-enterostomy 
and  entero-enterostomy  performed  by  the  late  W.  T.  Bull,  two  weeks 
later  with  une\-entful  recovery.  Remained  well  for  five  months  eating 
without  discomfort  and  gaining  steadily  in  flesh  and  strength.  At 
the  expiration  of  this  time  he  began  to  suft'er  pain  appearing  one  and 
one-half  to  two  hours  after  his  breakfast,  lasting  until  4  p.m.,  so  that 
he  could  eat  no  lunch.  The  pain  was  in  the  epigastrium,  shifting  some- 
what to  the  left.  After  the  subsidence  of  the  pain  he  would  feel  com- 
fortable enough  until  9  p.m.,  when  the  pain  would  reappear  and  continue 
throughout  the  greater  part  of  the  night,  gradually  waning  toward 
morning.  On  October  30,  two  weeks  after  pain  began,  the  patient 
was  examined.  Four  hours  after  a  breakfast  of  tea  and  toast  he  vomited 
a  large  quantity  of  brown  acid  fluid.  A  tube  was  passed  and  800  c.c.  of 
brown  acid  fluid  and  ancient  food  remains  were  removed.  Total  acidity 
00,  free  hydrochloric  acid  48.  The  following  morning  (October  31)  the 
fasting  stomach  contained  240  c.c.  of  clear  acid  fluid  without  admixture 
of  food  remains.  The  next  day  (November  1)  he  had  no  pain  whatever, 
and  the  fasting  stomach  was  empty,  but  on  November  2,  the  pain 
returned  and  five  hours  after  a  light  breakfast  1300  c.c.  of  fiuid  and 
food  remains  were  removed.  The  patient  was  put  to  bed  on  a  milk 
diet  for  one  week  and  ra])idly  improved.  Four  weeks  later  (December 
8)  he  began  to  comj>lain  again  of  heart-burn,  pyrosis,  and  pain  just 
to  the  left  of  the  median  line.  At  this  time  he  had  a  number  of  black 
tarry  stools  and  })ecame  quite  anemic.  Tube  at  7  p.m.  withdrew  2 
quarts  of  fluid  and  old  food  remains,  some  of  which  were  eaten  thirty- 
six   hours   ])re\i()usly.     The   following   morning   the   fasting   stomach 


JEJUNAL  AND  GASTROJEJUNAL   ULCERS  205 

contained  140  c.c.  of  fluid  and  food  remains  containing  a  large  amount 
of  altered  blood.    Total  acidity  58,  free  hydrochloric  acid  29. 

Decem})er  10,  patient  was  placed  on  the  von  Leube  ulcer  cure, 
during  the  first  three  weeks  of  which  he  complained  of  recurring  epi- 
gastric pain  relieved  by  food  and  alkalies.  Gastric  analysis  showed 
a  continuous  hypersecretion.  After  the  third  week  the  symptoms 
entirely  disappeared  and  he  remained  well  for  a  year,  eating  everything 
without  distress  and  gaining  in  strength.  On  December  14,  1903,  he 
was  chilled  while  duck  shooting,  vomited  several  pints  of  altered  blood, 
and  had  a  number  of  tarry  stools.  His  pain  returned  as  before,  and  on 
December  28  he  was  again  placed  on  the  von  Leube  ulcer  cure.  In 
this  ulcer  cure  pain  and  hypersecretion  continued  until  the  tenth  day, 
but  then  subsided  and  he  remained  well  until  April  1,  1904,  when 
his  symptoms  began  again  and  he  had  a  repetition  of  his  intestinal 
hemorrhages  and  was  placed  again  on  the  von  Leube  treatment.  During 
this  third  ulcer  cure  he  complained  of  severe  pains  from  the  tenth  to 
the  twentieth  day.  During  this  time  the  stomach  contents  w^ere 
aspirated  every  four  to  six  hours  by  the  tube,  the  estimated  hyper- 
secretion amounting  to  35  to  50  ounces  a  day.  From  the  thirtieth 
day  onward  his  hypersecretion  ceased  and  with  the  exception  of  one 
slight  attack  of  pain  and  hypersecretion  he  has  remained  well  until 
the  present  date,   a  period  of  nearly  nine  years. 

Diagnosis. — In  the  majority  of  the  reported  cases  the  diagnosis 
of  jejunal  or  gastrojejunal  ulcer  has  not  been  made  prior  to  perforation, 
the  diagnosis  being  either  made  at  operation  or  post  mortem,  so  that 
the  literature  of  the  subject  is  somewhat  restricted  to  the  ulcers  that 
actually  perforate,  those  that  do  not  rupture  remaining  undiagnos- 
ticated  and  unreported.  Consequently,  perforation  in  the  reported 
cases  is  of  extreme  frequency. 

Of  52  jejunal  and  gastrojejunal  ulcers  reported  by  Paterson*  perfora- 
tion occurred  in  general  peritoneal  cavity  in  19  cases. 

Perforation,  limited  by  adhesions,  resulted  in  inflammatory  exudation 
into  the  abdominal  wall  in  28  cases. 

Perforation,  limited  by  adhesions,  into  the  colon  in  5  cases. 

Perforation  into  General  Peritoneal  Cavity. — It  is  interesting  to  note 
that  of  the  19  instances  of  perforation  into  the  general  peritoneal 
cavity,  in  only  four  was  there  any  indication  that  the  result  of  the 
gastrojejunostomy  had  not  been  entirely  satisfactory.  Gastrojejunal 
ulcers  are  less  likely  than  the  jejunal  form  to  perforate  into  the  general 
peritoneal  cavity. 

]\Iaylard-  has  reported  an  interesting  case  of  two  consecutive  perfora- 

1  Proc.  Roy.  Soc.  Med.,  June,  1909.  ^  Lancet,  February  19,  1910,  p.  497. 


20G  EROSIONS  AND  RARE   ULCERS 

tions  of  peptic  jejunal  ulcer  following  gastrojejunostomy  for  a  perforated 
gastric  ulcer.  A  similar  instance  of  consecutive  perforation  is  recorded 
by  Battle.' 

The  symptoms  of  perforation  do  not  difi'er  in  any  material  way 
from  those  observed  in  the  course  of  gastric  or  duodenal  ulcerations. 

Perforation  into  the  Anterior  Abdominal  Wall. — There  is  a  group  of 
cases  in  which  the  ulcer  becomes  adherent  to  the  anterior  abdominal 
wall.  This  happened  in  28  out  of  52  of  Paterson's  cases.  The  ulcer 
being  shut  off  from  the  general  peritoneal  cavity,  the  adhesions  perforate 
and  form  a  cavit\-  in  the  substance  of  the  abdominal  wall.  The  history 
of  such  an  event  is  that  the  patient  will  complain  of  a  severe  pain, 
more  or  less  localized  over  the  upper  portion  of  the  right  rectus  or  the 
left  rectus  muscle,  with  tenderness  and  localized  rigidity  of  that  portion 
of  the  abdominal  wall.  A  hard  tender  swelling  may  be  distinctly  pal- 
pable, pften  of  the  size  of  the  fist.  The  distress  is  more  or  less  continuous, 
uninfluenced  by  the  taking  of  food,  but  is  usually  aggravated  by  any 
action  of  the  patient  which  throws  a  muscular  strain  on  that  portion 
of  the  abdomen.  In  certain  cases  a  fistula  forms,  from  which  ingested 
liquids  escape. 

Perforation  into  the  Colon. — A  rarer  complication  is  one  in  which  the 
ulcer  becomes  adherent  to  and  perforates  into  the  colon.  In  these 
cases  after  considerable  antecedent  abdominal  pain,  usually  quite 
intense,  the  patient  may  complain  of  eructations  having  the  odor  of 
sulphuretted  hydrogen,  followed  by  the  vomiting  of  fecal  material,  or 
of  fluid  having  a  markedly  fecal  odor.  Injections  of  colored  water,  such 
as  gentian  violet,  into  the  rectum  may  be  drawn  of!  from  the  stomach 
upon  passing  the  stomach-tube.  In  a  case  reported  by  Kaufmann^ 
there  formed  not  only  a  jejunocolic  fistula  but  a  gastrocolic  fistula  as 
well,  with  a  spontaneous  closing  of  the  gastrojejunal  anastomoses. 

Prognosis. — The  prognosis  is  difficult  to  determine  because  the 
statistics  are  largely  compiled  only  from  the  severe  cases  which  come 
to  a  secondary  operation,  but  the  outlook  is  always  grave  whether  the 
operation  is  done  or  not.  Cases  in  which  the  posterior  operation  has 
been  performed  usually  give  a  higher  rate  of  mortality  than  those  who 
have  been  subjected  to  the  anterior  operation,  because  in  the  former 
instance  the  ulcer  is  very  deeply  seated,  and  access  to  it  by  reason  of 
adhesions  is  often  tedious  and  difficult. 

Treatment. — Improvements  in  the  technique  of  gastrojejunostomy 
are  rcsi)()nsible  for  what  seems  to  be  a  diminishing  frequency  of  jejunal 
and  especially  of  gastrojejunal  ulcerations.  The  latter  form  is  considered 
by  Mayo  to  be  largely  due  to  a  failure  of  surgical  technique. 

'  LaiKX't,  190(),  ii.  1216  und  1247.  ^  Medical  News,  July  S,  1905. 


FOLLICULAR   ULCERATION  OF  THE  STOMACH  207 

Paterson  emphasizes  the  necessity  for  a  large  opening,  and  the  careful 
application  of  the  inner  suture  so  as  to  avoid  localized  necrosis  of  the 
tissues. 

The  necessity  for  after-treatment  of  cases  of  gastrojejunostomy 
has  not  received  sufficient  attention  by  the  surgeons.  Patients  after 
this  operation  are  ordinarily  allowed  to  eat  anything  without  restric- 
tion, and  it  seems  to  be  a  matter  of  personal  pride  on  the  part  of  the 
surgeon  that  his  patient  enjoys  an  unlimited  diet  within  a  few  weeks  of 
the  operation.  Such  a  course  of  action  cannot  be  too  strongly  condemned. 
A  patient  after  gastrojejunostomy  should  be  given  rigid  rules  as  to  his 
diet,  and  if  necessary  should  receive  appropriate  medical  care  for  at 
least  six  months,  or  until  such  a  time  as  examination  shows  that  the 
gastric  acidity  is  normal.  The  persistence  of  hyperacidity  after  gastro- 
jejunostomy is  due  either  to  extreme  hyperacidity  before  the  operation 
so  that  its  subsequent  natural  reduction  after  the  procedure  is  insuffi- 
cient to  reduce  it  to  normal  limits,  or  because  of  a  too  small,  ineffective, 
or  defective  anastomotic  opening.  Whether  or  not  indiscretion  in 
diet  may  induce  hyperacidity  with  a  normal  anastomotic  opening  is 
doubtful.  During  the  earl}^  postoperative  period,  and  especially  if 
the  patient  be  known  to  have  suffered  from  hyperacidity  or  hyper- 
secretion prior  to  the  operation,  repeated  doses  of  bicarbonate  of  soda 
or  of  other  alkalies  should  be  systematically  given,  and  the  diet  should 
be  that  of  the  second  or  third  week  of  the  ordinary  ulcer  diet. 

Stool  examination  should  be  made  from  time  to  time,  and  the  diet 
should  not  be  increased  should  blood  reaction  be  positive. 

When  the  symptoms  of  ulceration  appear  and  a  tentative  diagnosis 
is  made,  rigid  ulcer  cure  should  be  at  once  instigated.  Those  who  have 
read  Tiegel's  article  and  other  surgical  descriptions  of  the  operative 
treatment  of  these  cases  will  be  struck  by  the  numerous  difficulties 
which  attend  such  an  operation,  by  their  high  rate  of  mortality  and 
often  by  their  complete  failure  even  as  a  palliative  measure.  As  far  as 
possible,  therefore,  attempts  by  medical  means  should  be  made  to  favor 
the  healing  of  the  ulcer,  even  though,  as  in  the  case  cited  by  the  writer, 
the  ulcer  cure  be  frequently  repeated.  It  is  only  when  medical  means 
fail  that  surgical  intervention  is  to  be  advised. 

Perforation  is  regularly,  however,  to  be  treated  surgically  and  with- 
out delay.  Perforations  into  the  abdominal  wall  and  jejunal  colic 
fistula  are,  of  course,  to  be  considered  surgical  complications. 

FOLLICULAR   ULCERATION    OF    THE    STOMACH 

Owing  to  their  insignificant  size  and  deep  situation  in  the  mucous 
membrane,  the  solitary  glands  of  the  stomach  are  less  frequently  the 


208  EROSIONS  AND  RARE  ULCERS 

seat  of  disease  than  are  similar  glands  of  the  intestine.  In  certain 
infective  disorders,  however,  such  as  typhoid  fever,  acute  tuberculosis 
and  diphtheria,  as  well  as  a  number  of  inflammatory  conditions  of  the 
stomach,  these  glands  become  inflamed  and  undergo  necrosis.  Such 
a  process  results  in  small  ulcers,  which  are  usually  about  2  millimeters 
in  diameter,  with  overhanging  edges,  scattered  over  the  whole  surface 
of  the  mucous  membrane  of  the  stomach.  They  seldom  extend  deeper 
than  the  submucous  tissue,  although  it  is  possible  for  a  small  follicular 
ulceration  to  extend  its  area  in  all  directions  and  present  the  character- 
istic form  of  an  acute  perforating  ulceration.  As  an  evidence  of  the 
frequency  of  follicular  ulceration,  Fenwick  records  their  presence  in 
4  out  of  10  fatal  cases  of  acute  tuberculosis  examined  by  him. 

Symptoms. — Occurring  during  the  course  of  severe  infectious  diseases, 
such  as  tuberculosis  or  typhoid  fever,  the  symptoms  are  apt  to  be  ob- 
scured by  those  of  the  original  disease,  and  the  symptoms,  if  any, 
that  are  present  are  not  deemed  significant  of  any  gastric  disorder. 
Consequently  follicular  ulcer  of  the  stomach  is  an  ailment  concerning 
which  we  possess  but  little  clinical  knowledge. 

UREMIC   ULCERS 

Not  infrequently  erosions  or  ulcerations  are  found  in  certain  portions 
of  the  alimentary  tract  in  fatal  cases  of  Bright's  disease.  While  the 
lower  portion  of  the  ileiun  and  the  upper  portion  of  the  colon  are  the 
areas  most  affected,  ulcers  may  be  found  in  the  stomach,  especially 
in  the  pyloric  portion  and  in  the  duodenum.  Such  a  localization  is, 
however,  rare,  and  in  the  study  of  the  reported  cases,  there  is  often 
considerable  doubt  whether  the  ulcers  were  secondary  to  the  uremic 
state,  or  whether  they  were  independent  lesions,  merely  coexisting 
with  the  renal  disease.  Nevertheless,  it  seems  to  be  an  established 
fact  that  such  ulcers  may  occur.  In  the  stomach  the  lesions  are  found 
especially  in  the  i)yloric  end,  wiiile  in  the  duodenum  they  are  usually 
confined  to  the  first  portion.  Solitary  ulcers  are  more  frequent  than 
are  the  mnltiplc.  They  may  be  at  the  summit  of  the  valvulie  conniventes 
or  in  the  furrows  or  the  under  surface  of  these  folds.  Thej'  may  be 
only  surface  erosions,  or  deep  and  extensive,  so  that  perforation,  hemor- 
rhage, or  erosions  of  the  pancreas  may  occur.  The  direct  causation  of 
the  ulcers  c-annot  be  satisfactorily  explained, 

ULCERATION    OF    THE    DUODENUM    IN    CASES    OF    BURNS 

The  fact  that  duodenal  ulc<'ratiou  may  occur  as  a  compMcation  of 
extensive  burns  of  the  bodv  lias  been  known  for  many  years.     In  the 


VLCKRAriOX   OF   THE   DCODESTM   IN   CASES  OF  JiCRXS      2(M) 

older  litrratiire  of  the  subject  the  name  of  "Curling's  Ulcer"  was 
applied,  although  it  had  been  described  by  Long,  of  Liverpool,  tw(j 
years  before  Curling's  paper  was  published. 

The  ulcer  may  be  solitary  or  multiple,  and  although  the  lesion  is 
most  conspicuously  present  in  the  duodenum,  similar  ulcerations  may 
occur  in  the  stomach,  jejunum,  or  lower  ileum.  Of  29  cases  reported 
by  Perry  and  Shaw  a  single  ulcer  was  recorded  in  but  sixteen  instances. 
The  first  portion  of  the  duodenum  is  the  favorite  seat  of  selection, 
more  rarely  in  the  first  and  second,  or  in  the  second  part.  The  ulcer 
may  be  superficial,  or  deep  and  sloughing.  Acute  inflammation  of  the 
duodenum  is  almost  regularly  present  in  the  neighborhood  of  the  ulcer. 

This  complication  is  supposed  to  occur  in  about  6.2  per  cent,  of  ex- 
tensive superficial  burns,  and  occurs  twice  as  frequently  in  females 
as  in  males,  probably  because,  by  reason  of  the  difference  in  their 
clothing,  women  are  more  frequently  and  more  extensively  exposed 
to  burns  than  are  men. 

Etiology.— Duodenal  ulcer  complicating  burns  is  undoubtedly  of 
toxic  origin  and  is  comparable  with  the  ulcerations  seen  in  other  septic 
conditions.  It  is  the  rule  to  find  the  ulcer  only  when  septic  processes 
follow  the  sloughing  of  the  burnt  skin,  and  the  frequency  of  ulceration 
in  these  cases  depends  upon  the  frequency  in  which  the  suppurative  and 
septic  process  are  present.  It  has  been  surmised  by  some  that  the  ulcer 
may  be  due  to  septic  emboli  originating  in  the  infected  area,  producing 
hemorrhagic  erosions  in  the  alimentary  tract,  which  are  converted  to 
ulcers  by  autodigestion  in  those  portions  of  the  duodenum  that  are 
most  exposed  to  the  corrosive  action  of  the  gastric  juice. 

Symptoms. — In  a  number  of  cases  the  symptoms  of  duodenal  ulcer 
are  either  latent  or  so  obscured  by  those  of  the  burn  that  the  disease 
is  unsuspected  and  a  diagnosis  is  only  made  at  the  postmortem  examina- 
tion. In  the  majority  of  instances,  however,  hemorrhage  or. perforation 
occur  suddenly  as  the  first  indication  of  the  lesion.  In  20  of  the  29 
cases  reported  by  Perry  and  Shaw,  one  or  both  of  these  symptoms  were 
noted.  Hemorrhage  is  about  twice  as  frequent  as  perforation  and  may 
prove  fatal  as  early  as  the  fourth  or  fifth  day,  or  as  late  as  the  thirty- 
seventh  day  after  the  accident.  Its  maximum  frequency  occurs  about 
the  end  of  the  second  week.  Perforation  may  occur  between  the  fifth 
and  the  twenty-first  day. 

Prognosis. — Recovery  is  quite  exceptional.  Death  may  result  from 
the  burns  before  the  ulcer  has  time  to  perforate  or  bleed.  In  some 
instances  the  patient  lives  a  \ery  considerable  time  suft'ering  from 
suppurating  sloughs  and  the  symptoms  of  duodenal  ulcer  iiefore  death 
supervenes. 

Treatment. — Treatment  is  that  of  the  ordinary  form  of  acute  duodenal 
ulceration. 
14 


CHAPTER   VI 
CANCER   OF  THE   STOINJACH 

Cancer  of  the  stomach  is  unfortunately  a  frequent  event.  Of 
1,000,000  hospital  admissions,  Stockton  found  that  0.47  per  cent,  were 
suffering  from  this  disease.  One  per  cent,  of  all  hospital  cases,  according 
to  Eichhorst  were  found  affected  by  the  same  ailment.  These  figures 
are  somewhat  higher  than  those  observed  by  the  writer.  During  the 
years  1904  to  1908  there  were  admitted  to  Bellevue  Hospital  84,564 
medical  cases.  Of  these  143  were  diagnosticated  as  suffering  from 
cancer,  a  proportion  approximately  of  1  to  (500  patients. 

Postmortem  statistics  show  a  greater  frequency  of  disease.  In  50,000 
autopsies  compiled  by  Stockton  there  were  2000  cancers,  a  proportion 
of  4  per  cent.  Hale  White  has  calculated  that  1.5  per  cent,  of  all  deaths 
are  attributable  to  this  disease. 

The  stomach  is  a  very  favorite  seat  for  cancer,  so  that  nearly  one- 
half  of  all  cancers  are  gastric.  The  number  of  deaths  assigned  to  this 
disease  has  apparently  increased  from  year  to  year  in  practically  all 
countries.  This  fact  is  less  appalling  than  it  seems  at  first  sight  when 
we  consider  that  the  increased  number  of  cases  reported  does  not 
necessarily  mean  an  increase  in  the  actual  number  of  deaths  that  occur. 
As  more  attention  is  paid  to  the  collection  of  vital  statistics  greater 
accuracy  in  recording  causes  for  death  has  resulted,  so  that  the  number 
of  cancer  cases  reported  has  increased  with  the  increasing  efficiency 
of  registration  records.  Furthermore,  refinements  in  medical  diagnosis 
and  an  increased  number  of  surgical  operations  done  on  the  stomach, 
have  increased  the  mnnber  of  cases  in  which  a  positive  diagnosis  has 
been  made. 

Race.—  It  was  formerly  supposed  that  certain  races  were  less  sus- 
ceptible to  cancer  than  were  others.  It  is  somewhat  less  common  in 
negroes  than  in  the  whites,  and  was  supposed  to  be  rare  in  Egypt  and 
in  certain  parts  of  South  America.  While  the  manner  of  living  and 
variations  in  diet  in  dift'erent  races  may  increase  or  diminish  to  some 
extent  the  lial)ility  to  cancer,  these  difterences  after  all  are  slight,  and 
in  every  country  in  which  cancer  has  been  supposed  to  be  rare,  the 
establishment  of  bureaus  for  vital  statistics  has  shown  that  cancer  is  not 
as  rare  as  was  at  one  time  suj)posed.  In  Jai)an,  for  example,  where  it 
was  formerly  said  that  cancer  was  an  iiifrecinent  disease,  \ital  statistics 


HEREDITY  211 

now  exist  to  show  that  upward  of  25,000  deaths  from  cancer  occur 
every  year,  proving  that  the  condition  is  as  common  as  among  European 
races. 

Age. — Cancer  is  a  disease  having  a  well-known  age  incident,  the 
majority  of  cases  occurring  between  the  ages  of  forty  and  seventy. 
In  rarer  exceptions  the  disease  occurs  in  early  adult  life,  or  even  in 
childhood.  Osier  and  McCrae  have  reported  10  cases  in  literature 
of  cancer  of  the  stomach  in  children  under  ten  years  of  age,  and  13 
cases  between  the  ages  of  ten  and  twenty.  Congenital  cases  in  infants 
have  been  described  by  Williamson,  Weiderhofer,  and  Cullingworth. 
It  is  possible  that  these  congenital  cases  are  examples  rather  of  con- 
genital adenoma  than  of  cancer  proper.  In  young  children  the  majority 
of  cases  are  of  doubtful  authenticity,  as  many  of  them  were  noted  at  a 
time  when  the  finer  points  of  pathology  were  still  obscure.  Some  of 
them  were  apparently  instances  of  congenital  adenoma,  while  others 
were  without  doubt  examples  of  the  hypertrophic  pyloric  stenosis 
of  congenital  origin. 

The  influence  of  age  as  a  factor  in  cancer  is  shown  in  the  following 
table  of  the  author's  cases  and  those  from  other  writers  on  this  subject. 


10  to  20  years 
20  to  30  years 
30  to  40  years 
40  to  50  years 
50  to  60  years 
60  to  70  years 
70  to  80  years 
80  to  90  years 

Heredity. — i\Iost  of  the  recent  statistical  inquiries  have  tended  to 
disapprove  the  heredity  of  cancer,  but  statistical  inquiry  is  always 
unsatisfactory  because  figures  can  be  so  arranged,  although  in  perfect 
good  faith,  as  to  lead  to  widely  divergent  inferences.  The  ordinary 
method  employed  has  been  to  ascertain  what  percentage  of  cancer 
patients  gave  a  history  of  direct  heredity  in  their  forebears.  The 
general  conclusion  is  that  about  10  per  cent  of  afflicted  patients 
show  heredity  taint.  A  nearly  equal  percentage  is,  however,  obtained 
in  the  antecedents  of  those  dying  from  non-cancerous  disease. 

Bashford,  after  a  careful  study  of  the  subjects,  has  concluded  that 
those  dying  of  cancer  have  about  the  same  percentage  of  direct  heredity 
as  those  dying  from  all  cases  whatever,  cancerous  or  otherwise,  and 
Guillot  has  obtained  similar  results  in  his  investigations. 


Stockton  combined 

statistics  7000 

Lockwood 

cases. 

Osier. 

Eichhorst. 

Welsh. 

191  cases. 

Per  cent. 

Per  cent. 

Per  cent. 

Per  cent. 

Per  cent. 

0.08 

0.0 

0.0 

0.1 

0.0 

1.5 

4.0 

2.0 

2.7 

2.1 

8.8 

11.3 

8.0 

13.3 

11.5 

18.0 

25.3 

21.0 

24.5 

25.7 

28.0 

.32.6 

40.0 

30.4 

36.6 

28.0 

24.0 

26.0 

21.0 

18.9 

14.0 

2.6 

3.0 

6.8 

4.7 

2.0 

0.0 

0.0 

1.15 

0.5 

212  CANCER  OF  THE  STOMACH 

An  interesting  line  of  inquiry  has  to  do  with  the  frequency  of  cancer 
in  certain  famihes,  which  tends  to  show  that  while  heredity  may  not 
be  a  universal  factor,  it  undoubtedly  has  some  influence  in  determining 
malignancy  in  certain  cases.  "The  family  of  Madame  Z"  (reported 
by  Broca  and  investigated  by  Lebarde^)  showed  15  deaths  from  cancer 
in  26  offspring  who  attained  the  cancer  age.  Of  7  males,  only  one 
died  of  cancer;  of  17  females,  14  succumbefl  to  this  disease. 

Traumatism. — The  previous  history  of  traumatism  is  extremely 
infrequent  in  cancer,  and  its  rarity  is  commented  upon  by  various 
authors.  Occasionally,  however,  we  find  a  close  connection  between 
an  injury  and  the  symptoms  of  malignancy,  and  it  is  believed  that  in 
these  cases  the  local  injury  brings  out  symptoms  of  a  growth  previously 
latent  and  increases  the  rapidity  of  its  progress. 

Osier  reports  the  case  of  a  man  who  fell  from  a  wagon  while  in  good 
health,  and  for  a  while  was  rendered  unconscious.  The  next  day  he 
noticed  pain  in  the  epigastrium,  of  a  gnawing  character,  which  persisted 
until  his  death  ten  months  later.  During  this  time  he  vomited  food 
every  day,  but  never  any  blood.  Post  mortem  showed  cancer  of  the 
pylorus. 

In  other  instances  a  local  injury  may  originate  a  traumatic  ulcer, 
which  may  become  chronic  and  develop  malignant  degeneration. 
This  sequence  is  suggested  by  the  following  history: 

G.  B.,  aged  forty-nine  years.  Patient  drinks  about  3  pints  of  beer  a 
day,  denies  indulgence  in  stronger  liquors.  Xo  history  of  indigestion 
until  two  years  before  his  admission  to  the  hospital,  when  he  fell  from 
a  step-ladder,  landing  on  his  stomach.  Shortly  afterward  he  began  to 
complain  of  pain  in  the  epigastrium  coming  about  half  an  hour  after 
eating.  After  four  months  of  this  pain  he  vomited  a  basin  full  of 
black  l)lo()(l.  He  remained  in  bed  four  days,  after  which  time  his  pain 
ceased  and  he  remained  well  for  about  six  months.  The  pain  then 
returned  of  a  dull  aching  character;  he  vomited  both  food  and  coffee 
ground  material,  and  lost  forty  pounds  in  weight.  He  died  four  months 
after  his  admission  with  typical  symptoms  of  cancer. 

Aiitojjfii/. — Stomach  is  adherent  to  (lia])hragm,  t^ans^■erse  col-on, 
pancreas,  and  liver.  At  the  i)yl()ric  end,  one  inch  from  orifice,  is  an 
extensive  carcinomatous  growth  extending  along  the  lesser  curvature 
toward  the  cardia,  and  along  the  greater  curvature  for  one-third  its 
length,  (xrowths  in  li\(T  and  intestines  and  in  the  seventh  rib  in  the 
left  axillary  line. 

'  Quoted  by  Tysser,  Jour.  Amer.  Med.  A.ssoc.,  October  29,  1910,  p.  153().  Ijobarde'.s 
article  giving  the  family  chart  of  the  family  of  "Madame  Z"  \A'ill  be  found  in  Revue 
de  Mcdecin,  1908,  xxviii,  105. 


PATJlOIJHiy  213 

'I'lic  fiTowtli  was  so  oxtensix'e  that  it  \\as  iinpossihlc  at  the  au1()|)sy 
to  ])ro\c  its  ulcer  origin,  although  the  clinical  history  certainly  warranted 
such  an  assumption. 

Pathology. — ( 'ancer  of  the  stomach  consists  of  an  atypical  and  lawless 
proliferation  of  epithelial  cells  beginning  in  the  glands  of  the  mucosa, 
invading  successive  coats  of  the  stomach,  spreading  to  adjacent  organs 
directly,  and  involving  distant  parts  of  the  body  by  metastases  through 
the  lymphatic  channels  or  blood  stream. 

In  nearly  all  cases  the  carcinoma  is  primary  in  the  stomach,  sec- 
ondary cancers  being  comparatively  rare.  Welch  collected  37  cases, 
of  which  17  were  secondary  to  cancer  of  the  breast.  Martin  states 
that  combined  statistics  show  the  proportion  to  be  about  1.1  per  cent. 
i.  e.,  5  cases  out  of  440.  Fenwick  and  Fenwick,  in  their  series  of  2()5 
consecutive  necropsies  upon  cancer  of  the  stomach,  found  that  19, 
or  7  per  cent.,  were  secondary  to  disease  of  some  other  organ.  This 
estimate  closely  agrees  with  Hale  White's  6  to  7  per  cent. 

Fenwick  and  Fenwick  found  that  of  their  19  cases  "no  less  than  14, 
or  73.6  per  cent.,  were  due  to  direct  extension  of  the  disease  from  some 
neighboring  organ;  that  in  4,  or  21  per  cent.,  the  primary  complaint 
was  situated  in  the  upper  part  of  the  digestive  tract;  while  in  only  1,  or 
5  per  cent.,  was  the  gastric  affection  of  the  nature  of  a  true  metastasis." 

The  location  of  the  tumor  is  a  question  of  considerable  importance 
in  its  bearing  upon  the  symptoms  of  the  condition,  and  upon  the  changes 
in  the  stomach  itself.  Until  comparatively  recently  the  pylorus  was 
considered  by  far  the  most  frequent  site  of  the  tumor.  For  example, 
Welch,  in  an  analysis  of  1300  cases,  found  the  pylorus  in\'ohed  in 
60.8  per  cent.,  while  the  lesser  curvature  showed  but  11.4  per  cent, 
and  the  cardia  8  per  cent. 

In  reaching  a  solution  of  the  question  we  are  confronted  by  the 
same  problem  as  in  other  gastric  conditions;  that  is,  the  material 
obtained  at  autopsy  furnishes  unreliable  results.  The  neoplasm  is 
often  so  far  advanced  that  it  is  impossible  to  tell  where  it  began. 
More  recent  observations  have  been  made  on  specimens  obtained  at 
operation,  and,  as  a  result  of  these  studies,  the  lesser  curA'ature  has 
come  to  be  regarded  as  of  about  equal,  if  not  of  greater  importance 
as  the  site  of  origin  of  gastric  cancers.  Mikulicz  and  Kausch  belie^'e 
that  the  lesser  curvature  is  the  site  of  origin  in  about  40  per  cent,  of 
cases,  and  Boas,  in  studying  40  cases,  found  it  involved  in  62.5  per  cent, 
and  the  pylorus  in  12.5  per  cent.,  practically  reversing  Welch's  earlier 
figures. 

Fenwick,  in  an  analysis  of  1850  cases,  concludes  "that  in  79.4  per 
cent.,  or  in  about  four-fifths  of  all  cases,  carcinoma  commences  in  the 
comparatively  small  strip  of  tissue  which  extends  from  one  orifice 


214  CANCER  OF  THE  STOMACH 

to  the  other  nh)ii<j  the  ui)p(T  iiuirgin  of  the  stomach,  and  that  its  per- 
centage rapidly  (hminishes  the  fnrther  we  jjroceed  from  the  pyloric 
valve."  He  considers  it  of  relatively  little  importance  whether  the 
cancer  begins  at  the  pyloric  valve  and  spreads  inward,  or  develops 
on  the  lesser  curvature  near  the  orifice  and  becomes  sharply  limited 
by  the  valve. 

The  cardia  comes  next,  in  order  of  frequency,  the  anterior  and  pos- 
terior walls,  greater  curvature  and  fundus  being  less  commonly  afi'ected. 

Occasionally  one  finds  two  or  more  separate  growths  in  the  stomach. 
Thus,  in  Fenwick's  1850  cases  of  carcinoma,  there  were  multiple  growths 
in  54,  or  about  3  per  cent.  The  majority  of  these  cases  probably  repre- 
sents some  form  of  auto-infection.  Some,  however,  as  for  example 
where  there  is  a  tumor  at  either  orifice  of  the  stomach  presenting  different 
histological  pictures,  must  be  accepted  as  multiple  primary  tumors. 

Cancer  of  the  stomach  presents  a  varied  pathological  picture.  Con- 
siderable confusion  arises  in  the  various  classifications  given,  due  to 
the  fact  that  titles  descriptive  of  the  form  and  appearance  of  the  growth 
are  mixed  with  those  indicating  the  histological  picture  present.  Thus, 
we  see  the  terms  villous,  medullary,  encephaloid,  scirrhous,  cauliflower, 
colloid,  adenocarcinoma,  spheroidal-cell  carcinoma,  etc. 

It  is,  therefore,  much  better,  from  the  standpoint  of  clearness  and  of 
a  proper  appreciation  of  the  morphology  of  the  tumors,  to  divide  them 
on  a  histological  basis,  adding  the  various  descriptive  terms  in  their 
proper  places. 

Following  this  classification  we  may  recognize  three  main  types 
of  primary  gastric  carcinoma  (Fenwick). 

1.  Spheroidal  cell  or  glandular  carcinoma.  The  cells  are  spheroidal 
in  shape  and  similar  to  those  found  in  the  normal  gastric  tubules.  If 
these  tumors  are  rich  in  cells,  with  comparatively  little  stroma,  they  are 
known  as  medullary,  soft,  or  encephaloid  carcinomas;  while  if  there 
arc  but  few  cells  in  a  dense  fibrous  tissue  stroma,  the  term  scirrhous 
or  hard  is  applied. 

2.  Cylindrical  cell  or  adenocarcinoma.  Here  the  cells  are  of  cylin- 
drical or  cohnnnar  form,  and  resemble  those  found  in  the  i)yloric  glands. 

?i.  Colloid  carcinoma.  In  this  form,  which  represents  a  myxomatous 
degenerative  process  of  either  of  the  first  two  varieties,  both  the  cells 
and  stroma  may  be  converted  to  a  greater  or  less  degree  into  colloid 
material. 

While  the  foregoing  types  represent  clear-cut  differences,  it  must 
!)(•  reincmlxTcd  that  there  are  various  transitional  forms  which  i)resent 
a  more  complex  ])icture. 

Spheroidal-cell  Carcinoma  (Glandular). — Scirrhous  (Hard)  Form. — This 
type  of   carcinoma,  which    is  of  slow  growth  and  less  lial)le   to   form 


PATIIOLOdY 


215 


metastases  than  the  other  forms,  occurs  most  frequeiitl}'  in  the  pyloric 
region.  In  some  cases  it  may  completely  surround  the  pyloric  canal;  in 
others  it  may  appear  as  a  diffuse  infiltration  of  the  coats  of  the  stomach 
in  this  region,  with  raised  edges  and  depressed  centre,  resembling  a 
healed  scar  of  a  chronic  ulcer;  while  in  still  other  cases  one  may  see  at 
the  pylorus  a  localized,  more  or  less  globular  tumor,  with  some  cystic 
or  colloid  degeneration,  and  often  extensive  central  ulceration.  In  all 
of  these  forms  there  is  frequently  quite  marked  stenosis  of  the  pylorus, 
with  subsequent  dilatation  of  the  stomach.  The  mucous  membrane  over 
the  growth  is  indurated  and  tough,  immovable  upon  the  underlying 
tissues,  may  be  uneven  and  show  small  nodules  of  tumor  tissue.  Very 
often  there  is  superficial  or  deep  ulceration. 


Fig.  35 


Scirrhous  carcinoma  of  pylorus.  Pyloric  half  of  stomach  obtained  at  operation.  D,  duodenum; 
P,  pyloric  valve;  L,  lumen  of  the  much  contracted  pyloric  canal;  M,  muscularis  showing  the  inva- 
sion by  the  carcinoma,  C,  C.  The  white,  thickened  strands  of  connective  tissue  are  well  seen,  also 
the  hypertrophy  and  diffuse  carcinomatous  infiltration  of  the  muscularis  and  submucosa  graduallj' 
decreasing  in  intensity  toward  the  cardia. 

On  section  of  the  stomach  wall  through  the  tumor,  all  of  the  coats 
are  found  thickened,  especially  the  submucosa,  whose  slightly  concave, 
hard  surface  appears  smooth,  white,  and  glistening.  The  muscularis, 
especially  the  circular  coat,  is  considerably  hypertrophied,  and  is 
traversed  by  glistening  white  strands  of  connective  tissue. 

More  uncommonly  scirrhous  carcinoma  may  occur  as  a  dift'use  in- 
filtration of  the  whole  stomach  wall.  This  leads  to  great  increase  in 
thickness  of  the  gastric  wall,  generally  most  marked  at  the  pylorus, 
and   extreme   reduction   in   the   size  of  the  organ.      The  stomach  is 


210 


CANCER  OF   THE  STOMACH 


converted  into  a  toujih-walled,  incoUapsihle  tube,  in  the  extreme  eases 
having  a  capacity  of  only  one-haU"  to  three  ounces.  The  name  "  leather- 
bottle"  stomach  has  been  applied  to  this  condition. 

On  section,  the  submucosa  and  muscularis  are  found  especially 
thickened,  the  induration  gradually  diminishing  from  the  pylorus 
toward  the  cardia.  As  a  rule  the  indurated  mucous  membrane  shows 
some  ulceration.     It  may,  however,  be  tough  and  smooth. 


Fig.   30 


Diffuse  scirrhous  carcinoma  of  anterior  wall  of  stomach  viewed  from  behind.  The  mucous  membrane 
is  hypertrophied  and  the  rugse  are  stiff  and  thick.  An  irregular  area  of  ulceration  is  seen  at  X.  The 
thickening  of  the  submucosa  is  well  seen  at  S,  S.  The  muscularis  M  is  much  hypertrophied  and  is 
thickly  set  with  interlacing  bundles  of  fibrous  tissue.  The  pyloric  canal  P  is  narrowed  and  the  capacity 
of  the  stomach  much  reduced.  A,  pyloric  valve;  H,  duodenum.  (From  the  Pathological  Mu.seum 
of  the  Presbyterian  Hospital,  New  York.) 


It  may  be  very  difficult,  macroscopically,  to  distinguish  this  difi'use 
form  of  scirrhous  carcinoma  from  the  condition  known  as  "cirrhosit? 
ventriculi."  Even  with  the  aid  of  a  microscope  it  may  require  patient 
search,  and  even  serial  sections  to  settle  the  nature  of  the  lesion.  There 
are  many,  indeed,  who  doubt  the  existence  of  a  simi)le  cirrhosis  ven- 
triculi. Certain  it  is,  that  the  more  painstaking  the  mi(Tosc()i)ical 
examination  the  fewer  are  the  cases  of  simple  cirrhosis. 

Very  rarely  one  may  see  the  growth  most  marked  at  the  cardiac 
orifice,  or  as  an  annular  tumor  in  the  central  i)art  of  the  stomach. 
In  scirrhous  carcinoma  one  fre(|uently  sees  small  tumor  nodules  of  the 
serous  covering  of  the  stomach,  and  in  the  ])(Titoneuin. 


PATIIOIJHIY 


217 


jMicTuscopically,  one  finds  the  xarioiis  coats  (jf  the  stomach  thickened 
and  very  rich  in  connecti\e  tissue,  wliich  occurs  especially  in  irregularly 
branching  septa  of  varying  thickness.  Scattered  through  the  coats, 
but  occurring  especially  in  the  thickened  submucosa  and  along  the 
connective-tissue  septa  in  the  muscularis  are  found  small  nests  of  sphe- 
roidal and  atypical  epithelial  cells.  These  may  occur  in  small  tubules, 
but  more  often  as  solid  plugs  or  strands  of  cells  along  the  septa,  or 
penetrating  between  the  muscle  bundles.  They  may  be  more  or  less 
degenerated,  making  it  very  difficult  to  tell  whether  they  represent  a 
neoplastic  growth  or  not.  The  mucosa  generally  shows  the  changes 
of  chronic  productiN'e  gastritis,  often  with  ulceration.  It  may  be  in- 
vaded bv  the  tumor  tissue. 


Fig.   37 


Medullary  carcinoma  (spheroidal  cell)  on  posterior  wall  of  the  stomach  at  the  pylorus.  The  tumor 
i.s  of  the  typical  cauliflower  appearance.  There  i.s  some  superficial  ulceration  at  X.  P,  pyloric  ring; 
T,  tumor  mass,  sharply  circumscribed.    A  piece  of  tissue  has  been  removed  at  1'  for  sections. 


Mechdlary  {Soft)  Form. — These  growths  appear  typically  as  cauli- 
flower-like excrescences  of  soft,  exuberant,  succulent  tumor  tissue, 
attached  to  the  stomach  wall  by  a  broad  base.  They  are  grayish  white 
to  pale  pink  in  color,  generally  show  varying  degrees  of  irregular  ulcera- 
tion, have  a  dirty  looking  surface  or  one  discolored  by  hemorrhage, 
and  generally  extend  deeply  into  the  stomach  wall.  They  grow  rapidly, 
are  often  the  seat  of  hemorrhage,  and  form  early  metastases.  On 
account  of  the  resemblance  of  the  tumor  tissue  to  brain  substance  this 
type  of  growth  has  been  called  "encephaloid."    As  a  rule  these  tumors 


218 


CANCER  OF  THE  STOMACH 


appear  near  the  lesser  curvature  in  the  |)yl()ri('  half  of  the  stomach. 
At  times  the  growth  may  extend  for  some  distance  in  the  long  axis 
of  the  stomach,  and  rarely  the  cauliflower  growth  covers  practically  the 
whole  interior  of  the  stomach,  causing  great  reduction  in  its  capacity. 


Fig.  3S 


mil|llll|:'liprU|ill|||ll||llll|lll!||lM)r|||jl-ni 


0       fNCH! 


I  i  I  i  I  i  1 1  ijf  1 1|  I  ij]  ti  1 1 1  M  I  il  il 


Adenocarciiionia  of  the  papillary-polypoid  type  which  has  undergone  colloid  degeneration.  The 
exaggerated  polypoid  condition  i.s  well  .shown,  one  of  these  exulierant  masses  forming  a  bridge  of  tissue 
beneath  which  a  gla.s.s  rod  (.1)  has  been  placed.  Home  superficial  ulceration  is  shown  at  R.  The  honey- 
combed appearance  of  the  growth  appears  at  C.  I),  duixiciiuin.  (From  the  Pathological  Museum, 
Bellevue  Uospital,  New  York.) 


I  Iceration  is  \'ery  common,  at  times  being  so  extensive  that  only  a 
howl-shaped  ulcer,  with  raised,  ()\'erhangiiig,  or  gradually  sloping 
borders,  remains  (Aschoff's  soft,  ulcerating  type).  Not  infrequently 
one  finds  other  smaller,  flat  tumor  nodules  in  the  \icinity  of  the  large 
ulcer.    These  may  also  form  sui)erficial  ulcers. 

Occasionally,  medullary  carcinoma  infiltrates  the  walls  of  the  stomach 
diffusely,  causing  thickening  of  the  various  coats  and  a  hypertrophy 
of  the  mucous  membrane,  which  is  thrown  into  firm  folds  and 
ridges. 


rATiioLoav 


219 


Micr()sc()i)i('all\'  the  i)i('tur('  is  (|uit('  the  reverse  of  the  scirrhous  form. 
The  stroma  is  scanty,  the  cell  richness  great.  The  alveoli  are  large, 
irregular,  tortuous,  and  numerous,  and  they  are  filled  with  oval  or 
spheroidal  cells.  The  mucous  meml)rane  is  the  seat  of  widely  growing 
tumor  tissue  of  the  same  type.  It  shows  early  ulceration.  It  is  also 
noticeable  that  the  deepest  layers  of  the  stomach  wall  are  infiltrated 
l)v  the  growtii  at  an  early  date. 


Fig.  39 


Adenocarcinoma  of  the  stomach.  M,  mucosa  showing  considerable  infiltration,  with  mononuclear 
wandering  cells  at  X;  MM,  muscularis  mucosse,  with  infiltration  of  the  carcinoma,  as  at  .4; 
S,  submucosa  and  muscularis,  with  extensive  carcinomatous  infiltration. 


Cylindrical-cell  Carcinoma  (Adenocarcinoma). — This  type  is  repre- 
sented by  a  large,  red  fungus  outgrowth  from  the  mucosa  of  the 
stomach,  having  a  broad  base  and  a  villous-like  surface.  While  soft 
in  consistence,  these  tumors  are  firmer  than  the  medullary  cancers,  and 
they  are  more  superficial.  They  are  moderately  succulent,  very  prone 
to  hemorrhage,  and  often  the  seat  of  extensive  ulceration.  Occasionally 
they  occur  in  girdle  form  about  the  central  portion  of  the  stomach, 
or  near  the  pylorus.     Like  the  other  varieties,   adenocarcinoma  may 


220 


C'AXf'ER  OF   THE  STOMACH 


infiltrate  the  stoinacli  walls  diH'uscly.  In  this  form  the  jnlorus  is 
usually  thiekened  and  rigidly  ])atent  rather  than  contracted. 

On  microscopical  examination,  the  tumor  is  seen  to  consist  of  numer- 
ous large  alveoli  of  various  shapes  and  sizes  in  a  fine  stroma  of  fibrous 
tissue,  rich  in  bloodvessels.  While  in  many  parts  of  the  tumor  the  cells 
may  be  atypical  in  shape,  one  can  find  alveoli,  generally  in  the  deeper 
layers,  lined  with  ty))ical  columnar  epithelium. 

Colloid  Carcinoma. — This  type  is  more  uncommon  and  represents  a 
degeneration  form.  It  may  occur  late  or  so  early  that  even  the  growing 
edge  of  the  tumor  presents  a  gelatinous  appearance.  It  generally  in- 
vades all  the  coats  of  the  stomach,  and  spreads  rapidly  to  adjacent 


Fig.   40 


Extcnsivo  colloiil,  sliDwing  the  incroasod   thickness  of  the  stomach  wall. 
Laboratory  of  Mt.  Sinai  Ho.spital.) 


(From  tho    P!itli()l<)(;ii-:il 


tissues,  especially  the  omentum  and  peritoneimi.  The  mucosa  is  gen- 
erally thickened  and  may  l)e  very  rough,  witli  irregular  protuberances 
in  extreme  cases  resembling  polyposis.  On  section  the  thickened  walls 
appear  honey-combed  with  larger  and  smaller  alveoli,  filled  with  yellowish 
or  brownish  gelatin()u.s  material  which  oozes  out  on  pressure.  Colloid 
carcinoma  may  appear  as  a  circumscribed  mass  of  light  brown  color 
and  slimy  consistence. 

On  microscopical  examination  one  sees  various  sized  alveoli,  more  or 
less  completely  filled  with  the  jx'culiar  strings-  colloid  material.  Here 
and  there,  many  ahcoli  liaxc  aliiiost  coinplctcly  disintegrated,  leax'ing 


I'ATIIOLOdY 


221 


large  spaces  filled  with  colloid  and  showing  irregular  loops  or  strands 
of  epithelial  cells.  These  cells  often  show  granular  or  fatty  changes. 
The  septa  may  also  appear  to  take  part  in  the  degeneration,  showing 
long,  slimy  processes,  or  being  almost  entirely  disintegrated.  At  the 
margins  of  the  tumor  it  is  generally  possible  to  find  some  traces  of  the 
carcinoma  in  which  the  degeneration  is  taking  place.  More  rarely 
one  finds  such  degeneration  taking  place  in  a  scirrhous  cancer. 


Colloid  carcinoma  at  the  pylorus.  The  tumor  {T)  is  rather  sharply  demarcated  from  the  rest  of 
the  stomach  (S).  The  pylorus  (P)  is  moderately  obstructed.  The  great  thickening  of  the  stomach 
wall  is  shown  at  .4,  ^4.  Note  the'large  increase  in  tissue  outside  the  muscularis,  B,  B.  (From  the 
Pathological  Museum,  Columbia  University,  New  York.) 


In  addition  to  these  primary  forms  one  must  recognize  the  rare 
squamous-cell  carcinoma,  which  is  always  secondary.  These  tumors 
are  usually  seen  at  the  cardiac  orifice,  and  represent  direct  extensions  of 
a  primary  epithelioma  of  the  esophagus.  Rarely  this  type  of  carcinoma 
is  seen  in  other  portions  of  the  stomach  as  a  secondary  nodule  caused 
by  transplantation  of  a  piece  of  tissue  from  a  similar  tumor  of  the  tongue 
or  esophagus. 

Frequency  of  the  Different  Types. — The  early  figures  of  Brinton,  in 
which  he  fouiul  that  72  per  cent,  of  gastric  cancers  were  of  the  scirrhous 


222  CANCER  OF  THE  STOMACH 

variety,  19  per  cent,  of  medullary,  and  9.4  per  cent,  colloid,  have  been 
quite  generally  discarded  as  valueless.  Perry  and  Shaw,  from  a  micro- 
scopical study  of  44  specimens  of  gastric  carcinoma,  found  that  32 
were  spheroidal  cell  and  12  were  cylindrical  cell.  Fenwick  and  Fen- 
wick,  in  115  cases,  find  that  73,  or  03.5  per  cent.,  are  spheroidal  cell,  33, 
or  2S.()  per  cent.,  are  cylindrical  cell,  and  9,  or  7.S  per  cent.,  are  colloid, 
and  in  41  of  the  spheroidal-cell  cancers,  22  were  medullary  and  19 
were  scirrhous. 

Changes  in  the  Shape  of  the  Stomach. — These  are  not  so  simple  as  one 
would  expect.  Thus  in  disease  affecting  the  i)yl()rus,  it  is  natural  to 
assume  that  with  the  resulting  stenosis,  there  must  follow  a  dilatation 
of  the  stomach.  But  Lehert  found  that  in  20  cases  in  which  the  pylorus 
was  obstructed,  the  stomach  was  dilated  in  13,  and  contracted  in  7; 
and  in  9  cases  in  which  both  orifices  were  free,  there  was  dilatation  in 
4,  and  contraction  in  5.  Fenwick  and  Fenwick,  in  98  cases  of  pyloric 
disease,  find  the  stomach  "dilated  in  52,  normal  in  10,  and  contracted 
in  36." 

It  is  evident,  therefore,  that  there  are  other  factors  at  work  aside 
from  the  primary  disease.  If  the  neoplasm  is  situated  at  the  pylorus, 
and  causes  ol  struction,  there  is  generally  an  increase  in  the  size  of  the 
stomach.  AVhen  the  organ  is  contracted  under  these  conditions,  it  is 
usually  due  to  a  dift'use  infiltration  of  the  stomach  wall  by  a  scirrhous 
carcinoma.  The  other  forms  of  difi'use  cancer  may  also  cause  contrac- 
tion. In  other  cases  it  may  he  due  to  the  constant  \'omiting  which 
takes  place  in  these  cases  late  in  the  disease,  and  which  keeps  the 
stomach  constantly  em])ty.  Again,  adhesions  to  contiguous  organs 
may  cause  contraction. 

In  the  cases  of  rigid  patency  of  the  pylorus,  the  dilatation  which  often 
ensues  may  be  explained  by  the  destruction  of  the  muscular  tissue 
in  the  pylorus,  a  similar  dilatation  of  the  lower  esoj^hagus  being  found 
when  there  is  a  paralysis  of  its  sphincter. 

When  the  tumor  causes  obstruction  at  the  cardiac  orifice,  the  organ 
is  almost  invariably  wasted  and  contracted.  Occasionally  one  sees 
irregular  deformities  in  the  shape  of  the  stomach,  such  as  th(>  \arious 
forms  of  hour-glass  constriction,  due  to  a  more  or  less  aiuuilar  growth 
at  some  point  between  the  two  orifices. 

Changes  in  the  Mucous  Membrane. — The  nnicous  mcmi)rane  of  the 
stomach  not  directly  afiected  by  the  tumor,  usually  shows  more  or  less 
atrophy  f)f  the  glands,  in\()lving  particularly  the  |)arietal  cells,  with 
interglandular  rouiid-ccll  infiltration.  This  atrophy  is  probably  a 
.secondary  change,  and  not  a  i)rimarv  one  upon  which  carcinoma 
develops,  as  some  ob.ser\ers,  notable  Ilayem  and  Mathieu,  would  have 
us  l)elieve. 


SYMI'TOMS  OF   CANCER  223 

The  various  complications  wiiich  may  develop  from  cancer  of  the 
stomach,  as  well  as  the  metastases  which  occur,  are  dealt  with  in  sep- 
arate paragraphs. 

Epithelioma  of  the  stomach  is  rare,  there  being  but  five  reported 
cases  in  literature. 

SYMPTOMS    OF    CANCER 

Precancerous  History. — There  is  no  doubt  whatever  that  a  certain 
percentage  of  chronic  gastric  ulcers  develop  malignancy,  nor  can  it  be 
disputed  that  many  such  cases  of  malignancy  give  a  clinical  history 
of  a  long-standing  preceding  ulcer.  The  frequency  of  such  a  malignant 
degeneration  and  the  percentage  of  cases  of  malignancy  that  give  a 
previous  ulcer  history  vary  greatly  in  the  experience  of  different  writers. 
The  points  to  be  decided,  therefore,  are  what  percentage  of  gastric 
cancers  arise  from  ulcer,  and  second  in  what  percentage  of  cancer  cases 
is  such  a  history  of  previous  ulcer  obtainable. 

The  earlier  writers  estimate  the  frequency  of  the  ulcer  origin  of 
cancer  as  6  to  8  per  cent.,  basing  their  conclusions  on  the  results  of 
postmortem  examination.  Owing  to  the  extensive  growth  and  ulceration 
of  the  neoplasm  as  seen  at  autopsy,  it  is  often  impossible  to  decide 
whether  signs  of  previous  ulcer  are  present.  It  is  therefore  to  the 
surgeon  who  has  the  opportunity  to  examine  during  the  early  stages 
of  malignancy  that  we  must  look  for  accurate  data  on  this  subject. 

Wilson  and  MacCarthy,i  writing  from  the  Mayo  clinic,  report  that 
of  153  specimens  of  undoubted  carcinoma  taken  from  the  stomach  at 
time  of  operation,  71  per  cent,  "presented  sufficient  gross  and  micro- 
scopical evidence  of  previous  ulcer  to  warrant  placing  them  in  a  group 
labelled  'carcinoma  developing  from  previous  ulcer.'  Eleven  other 
cases  (7  per  cent.)  showed  considerable  evidence  of  precedent  ulcer, 
but  not  sufficient  to  warrant  placing  them  in  the  previous  group.  In 
33  cases  (22  per  cent.)  there  was  relatively  small  or  no  pathological 
evidence  of  precedent  ulcer." 

These  figures  are  sufficiently  appalling  to  make  us  pause.  If  71  per 
cent,  of  cancers  arise  from  ulcer,  excision  of  an  ulcer  whenever  it  is 
diagnosticated  would  be  a  justifiable  precautionary  measure.  It  is  to 
be  remembered,  however,  that  the  Mayo  clinic  receives,  as  a  rule,  only 
the  chronic  ulcers  which  have  resisted  all  forms  of  medical  treatment 
and  which  are  sufficiently  aggressive  in  their  clinical  course  as  to  be 
no  longer  endurable  by  the  patient.  It  naturally  would  follow,  there- 
fore, that  these  figures  do  not  apply  to  all  classes  of  ulcer  which  are 

1  Amer.  Jour.  Med.  Sci.,  December,  1900. 


224  CA.XCER  OF   THE  STOMACH 

seen  by  the  internist.  There  is  one  point,  however,  that  throws  some 
doubts  in  the  writer's  mind  as  to  the  correctness  of  these  figures.  Those 
who  have  for  years  been  treating  ulcer  of  the  stomach  and  who  for 
long  periods  of  time  have  followed  up  their  ulcer  cases,  do  not  find 
that  such  patients  are  apt  to  develop  malignancy,  at  least  from  a  clinical 
point  of  view.  The  writer  has  traced  a  large  majority  of  the  ulcer 
cases  treated  by  him  in  the  past  twenty  years,  and  has  been  impressed 
by  the  small  number  of  those  who  have  developed  malignancy.  It  is 
impossible  to  give  accurate  figures  owing  to  the  difficulty  of  tracing 
many  of  the  patients,  but  his  general  impression  is  that  in  not  more 
than  ?i  or  4  per  cent,  of  his  ulcer  cases  have  the  symptoms  of  malignancy 
supervened. 

The  number  of  patients  with  cancer  who  give  the  history  of  a  previous 
ulcer  is  differently  given  by  the  physician  and  by  the  surgeon.  In  the 
Mayo  clinic  it  is  estimated  that  in  about  oO  per  cent,  such  a  previous 
history  is  obtainable.  Robson^  writes:  "In  no  less  than  59.3  per  cent, 
of  cases  of  cancer  of  the  stomach  on  which  I  have  performed  gastro- 
enterostomy for  the  relief  of  symptoms,  the  disease  having  advanced 
too  far  for  gastrectomy,  the  long  history  of  painful  dyspepsia  suggests 
the  possibility  of  ulcer  preceding  the  onset  of  malignant  disease." 
This  is  quite  contrary  to  Robson's'  previous  belief,  for  he  wrote  of 
cancer  six  years  previously:  "It  is,  however,  rare  to  elicit  a  history 
of  very  old  standing  stomach  disorder;  the  first  evidences  of  local  dis- 
ease appear  suddenly  in  persons  of  perfectly  sound  health  and  robust 
digestion." 

On  the  other  hand,  statistics  from  purely  medical  sources  indicate 
that  a  previous  ulcer  history  is  extremely  infrequent  in  cancer  cases. 
In  only  four  of  150  cancers  of  the  stomach  reported  by  Osier  was 
there  an  ulcer  history  (2.()  per  cent.),  and  in  not  one  of  the  four  was  the 
ulcer  history  clean-cut  or  definite. 

Fenwick  in  iiis  cases  found  but  M  per  cent,  admitted  a  previous  ulcer 
history,  while  Eichhorst  states  that  in  only  2  per  cent,  of  the  cancer 
cases  observefl  in  the  Zurich  clinic  could  such  a  history  be  elicited. 
The  author's  experience  is  as  follows: 

Of  174  cases  of  cancer  of  the  stomach  in  which  the  history  could 
be  com])letely  taken,  14(S  ga\'e  no  history  whatever  of  ])re\ious  indiges- 
tion. Thirteen  gave  a  history  of  indigestion,  either  most  indefinite 
and  not  in  the  least  suggesting  ulcer,  or  else  of  the  indigestion  due  to 
alcoholism  in  its  t\pical  form,  while  only  ]'.]  ga\e  a  history  that  ))ointed 
to  i)rc\ious  ulceration.     Thus  a  clinical  ulcer  histor\'  was  obtained  in 

'  Can(;er  of  I  he  SloiiKifh,  I'.KIT. 

2  Robson  ami  Moyiiiliaii,  Surgical  'I'rcatiiicnl  of  tlip  Disca.se.s  of  tho  Stomach,  1901. 


SYMPTOMS  OF  CANCER  225 

only  7  per  cent,  of  the  cases.  It  is,  therefore,  the  experience  of  the 
writer  that  an  antecedent  history  of  indigestion  in  the  cancer  cases  is 
not  more  common  than  in  a  similar  number  of  non-malignant  cases 
taken  from  corresponding  walks  of  life,  and  that  one  of  the  most  striking 
phenomenon  of  malignant  disease  of  the  stomach  is  the  sudden  occurrence 
of  dyspepsia  in  those  of  cancer  age  who  have  previously  been  free  from  all 
indigestion. 

When  cancer  follows  gastric  ulcer  two  clinical  types  are  encountered. 
In  the  majority  of  cases  the  symptoms  of  ulcer  merge  gradually  into 
those  of  the  malignant  invasion,  the  change  being  accompanied  by  a 
falling  off  in  weight,  an  increasing  chloranemia,  and  by  an  aggravation 
and  increased  constancy  of  the  pain.  Emesis  rarely  affords  anything 
like  its  former  relief.  Sudden  anorexia  is  apt  to  occur.  Occult  blood 
is  almost  invariably  present  in  the  stools,  and  is  highly  suggestive  if 
it  persist  in  a  patient  with  gastric  ulcer  who  has  been  for  two  weeks 
on  a  milk  diet. 

On  order  that  this  change  to  malignancy  be  not  overlooked,  ulcer 
patients  should  be  repeatedly  weighed  and  their  stools  systematically 
examined. 

In  other  cases  the  ulcer  symptoms  may  have  subsided  months  or 
years  previously,  without  any  digestive  symptoms  in  the  interval, 
until  the  onset  of  gastric  distress  that  may  seem  to  indicate  a  recurrence 
of  the  ulcer,  but  which  in  reality  is  due  to  the  beginning  of  a  malignant 
growth. 

Local  Symptoms. — Pain. — It  is  improbable  that  cancer  of  the  stomach 
can  exist  without  giving  rise  to  local  discomfort  or  pain  at  some  time 
or  another  during  its  course.  In  many  cases,  however,  the  discomfort 
is  so  slight,  or  occurs  at  such  long  intervals,  that  no  mention  is  made 
of  it  except  under  the  most  searching  questioning,  and  it  stands  re- 
corded on  the  history  that  the  patient  has  at  no  time  suffered  from  pain 
or  discomfort  connected  with  the  digestive  act. 

Actual  pain  is  absent  in  a  large  number  of  gastric  cancers  throughout 
their  entire  course.  In  the  writer's  hospital  cases,  174  in  number, 
21  per  cent,  were  entirely  painless.  This  closely  agrees  with  the  Royal 
Victoria  Hospital  statistics,  in  which  22  per  cent,  of  the  patients  made 
no  mention  of  pain. 

In  private  practice  the  proportion  of  the  painless  cases  is  much  less, 
15  per  cent,  of  the  writer's  private  cases  being  unaccompanied  by  any 
pain  whatever,  thus  closely  tallying  with  Osier's  13  per  cent,  of  a  similar 
painless  course. 

Pain  when  present  is  apt  to  be  a  prominent  symptom  of  the  disease, 
although  its  intensity  is  not,  as  a  rule,  excessive.  The  pain  is  usually 
situated  in  the  epigastrium,  and  is  somewhat  less  sharply  localized 
15 


226  CASCER  OF   THE  STOMACH 

than  is  the  case  with  ulcer.  Radiation  of  the  pain  may  occur,  but  is 
less  frequent  than  in  ulcer.  In  three  of  the  writer's  cases  the  pain 
was  referred  exclusively  to  the  left  iliac  fossa,  a  localization  of  pain 
not  uncommon  in  ulcers  involving  the  lesser  curvature  near  the  cardia. 

Pain  referred  to  the  chest  or  the  lower  end  of  the  sternum  may  occur, 
usually  but  not  invariably  associated  with  the  growths  near  the  cardia. 
Pain  in  the  left  shoulder  may  occur  as  an  initial  symptom,  either  alone 
or  associated  with  epigastric  distress. 

The  character  of  the  pain  varies  more  than  with  ulcer.  In  a  large 
number  of  cases  (37  per  cent,  of  the  hospital  series  and  21  per  cent,  of 
the  private  cases)  no  description  of  the  pain  is  given.  This  large  number 
of  cases  implies  a  certain  indefiniteness  in  the  character  of  the  pain. 
The  patient  is  unable  to  describe  it  as  accurately  as  can  the  patient 
with  ulcer,  a  fact  which  is  of  considerable  importance  in  the  differential 
diagnosis  of  the  two  conditions. 

When  the  pain  can  be  described,  it  is  usually  of  a  dull,  aching  character 
— an  "aching  soreness."  This  pain  occurred  in  26  per  cent,  of  the  hos- 
pital cases  and  in  14  per  cent,  of  the  private  patients.  Pain  of  a  sharp, 
lancinating  character  occurs  in  only  a  small  number  of  cases  (6  per 
cent,  hospital,  5  per  cent,  private).  Pain  of  a  crampy  colicky  character 
is  not  infrequently  seen  with  pyloric  situation  of  the  growth,  although 
it  has  been  observed  in  cases  in  which  the  pyloric  orifice  is  entirely 
patent.  Pain  described  as  "gnawing"  occurred  in  only  2  per  cent, 
of  the  cases. 

The  relationship  of  the  pain  in  cancer  to  eating  is  rarely  as  marked 
as  in  ulcers,  as  the  pain  of  the  neoplasm  shows  a  far  greater  tendency 
to  constancy.  In  the  majority  of  cases  there  is  complaint  of  a  more 
or  less  constant  pain,  some  degree  of  discomfort  being  almost  always 
present,  amounting  at  times  to  exacerbations  of  considerable  severity. 
In  a  certain  number  of  cases  these  exacerbations  bear  no  relation- 
ship to  the  taking  of  food,  but  in  the  majority  of  instances,  an 
increase  in  the  pain  after  meals  is  the  usual  complaint,  the  duration 
of  time  between  the  ingestion  of  food  and  the  appearance  of  the  pain 
varying  from  a  few  minutes  to  several  hours. 

Cancers  of  the  cardia  are  usually  characterized  by  pain  during  or 
shortly  after  deglutition.  Constant  pain,  uninfluenced  by  the  ingestion 
of  food,  suggests  extension  to  the  peritoneum.  In  these  cases  the  pain 
is  frequently  increased  by  exercise  or  by  deep  breathing. 

In  the  series  of  private  cases  30  per  cent,  complained  of  pain,  or  of  a 
"burning  distress,"  appearing  two  or  three  hours  after  meals,  relieved 
by  eating  or  by  taking  soda.  In  these  ca.ses  the  difl'erential  diagnosis 
from  ulcer  wouKI  have  been  almost  impossible  ha<i  it  not  been  for  the 
deductions  furnisherl   by  the  frcfjueiit  or  fonstant  ijrcscnfc  of  occult 


SYMPTOMS  OF  CAXCER  227 

blood  in  the  stools,  persisting  after  the  rigid  enforcement  of  milk  or 
liquid  diet.    A  further  reference  to  these  cases  will  later  be  made. 

In  the  hospital  series  of  cases,  this  form  of  pain  seemed  to  be  com- 
paratively rare,  and  the  relief  to  the  pain  afforded  by  eating  occurred 
only  in  a  few  instances. 

It  is  a  diagnostic  point  of  considerable  importance  that  the  pain 
of  cancer  is  less  amenable  to  liquid  or  bland  diet  than  that  of  ulcer. 
In  a  case  of  doubtful  diagnosis,  pain  persisting  after  a  week  of  pep- 
tonized milk  diet  is  presumably  due  to  cancer  rather  than  to  ulcer. 
Orthoform,  anesthesin,  and  soda  do  not  relieve  the  pain  in  cancer  as 
they  do  in  ulcer.  Although  remissions  or  intermissions  of  the  cancer 
pain  are  not  as  frequently  observed  as  in  ulcer,  it  by  no  means  follows 
that  the  pain  should  be  continuous.  Very  frequently  patients  with 
cancer,  and  suffering  often  to  an  extreme  degree,  enter  the  hospital, 
and  leave  with  greatly  diminished  pain  or  even  with  no  pain  at  all. 
Unfortunately  many  of  these  cases  pass  from  observation  and  the 
diagnosis  never  becomes  established. 

Cessation  of  pain  may  also  occur  in  cases  of  pyloric  stenosis  from 
the  ulceration  of  an  occluding  growth  at  that  orifice,  thus  ^elie^-ing 
the  stenotic  condition.  In  these  instances,  however,  the  cessation 
of  pain  is  not  accompanied  by  any  improvement  in  the  patient's  con- 
dition, but  rather  by  an  increase  in  his  weakness  and  cachexia. 

Cessation  of  pain  may  also  follow  the  formation  of  a  gastrocolic 
fistula.  Physical  and  psychical  shocks  may  in  some  imknown  manner 
largely  influence  for  the  better  the  pain  and  distress.  It  is  frequently 
observed  that  after  operations,  even  simple  explorations  without 
exsection  or  gastrojejunostomy,  the  patient's  pain  and  vomiting  cease 
and  the  general  condition  improves  to  an  extraordinary  degree.  This 
is  a  point  of  considerable  interest,  and  should  be  borne  in  mind  in 
advising  surgical  exploration  in  doubtful  cases,  in  which  the  actual 
risk  of  the  operation  is  slight,  but  in  which  the  temporary  advantages 
may  be  extremely  gratifying.  A  remarkable  instance  of  this  is  the 
following  case: 

T.  ^I.,  aged  forty-nine  years.  Readmitted  to  hospital  vSeptember 
26.  1905,  with  the  following  history:  His  mother  died  in  late  adult 
life  from  "dysentery"  of  sLx  months'  duration.  Patient  is  moderately 
alcoholic,  denies  syphilis,  and  says  he  has  never  been  seriously  ill  until 
his  present  trouble.  Xo  history  of  gastric  ulcer  can  be  obtained. 
Fifteen  months  ago  he  began  to  suft'er  from  severe  epigastric  pam, 
more  or  less  constant  vomiting,  and  noticed  that  in  a  month  he  had 
lost  40  pounds  in  weight. 

One  month  after  the  onset  of  his  illness  he  was  first  admitted  to  the 
hospital.    At  this  time  the  fasting  stomach  was  empty.    Test  breakfast 


228  CANCER  OF  THE  STOMACH 

showed  200  c.c.  well-digested  breadstuff,  total  acidity  30.      No  free 
hydrochloric  acid,  no  lactic  acid,  Oppler-Boas  bacilli,  nor  blood. 

Exploratory  operation  a  few  days  afterward  revealed  a  cancer  mass 
at  the  pylorus  and  pyloric  end  of  the  stomach.  Gastro-enterostomy 
was  done,  but  no  attempt  was  made  to  remove  the  growth. 

Recovery  from  operation  was  uneventful,  and  the  patient  left  the 
hospital  free  from  pain  and  vomiting.  For  thirteen  and  a  half  months 
he  worked  as  a  longshoreman,  ate  everything,  gained  50  pounds  in 
weight,  and  had  absolutely  no  pain  or  distress  whatever,  and  did 
not  vomit.  Two  weeks  before  readmission  he  began  to  complain  of 
constant  abdominal  pain  and  tenderness,  vomited  from  time  to  time, 
and  suddenly  became  exceedingly  weak: 

Physical  Examination. — On  his  readmission  he  appeared  as  a  cachectic 
emanicated  man  with  slight  jaundice.  There  was  marked  tenderness 
over  the  upper  part  of  the  abdomen  and  well-marked  rigidity  of  the 
abdominal  wall.  Examination  under  chloroform  anesthesia  revealed 
a  large  irregular  immovable  mass  in  the  epigastrium.  The  growth 
apparently  involved  the  peritoneum. 

His  weakness  rapidly  increased,  vomiting  and  pain  were  constant 
and  distressing,  and  he  died  two  weeks  after  his  readmission  and  four 
weeks  after  the  reappearance  of  his  symptoms. 

Similar  instances  of  temporary  relief  from  pain  occur  after  nervous 
shocks,  as  is  shown  in  the  following  instance. 

An  elderly  lady  was  seen  in  consultation  suffering  from  typical 
advanced  symptoms  of  gastric  carcinoma  with  a  large  nodular  mass 
in  the  epigastrium.  Her  condition  was  so  bad  that  it  did  not  seem 
])ossible  that  she  could  live  more  than  one  or  two  days.  A  few  hours 
afterward  the  hotel  in  which  she  lived  took  fire,  and  after  many  excit- 
ing episodes  she  was  finally  rescued,  clad  only  in  her  night-dress,  and 
taken  by  ambulance  to  another  apartment.  From  that  time  she  had 
no  pain,  vomiting,  or  distress  for  over  three  months,  ate  everything, 
and  gained  daily  in  flesh  and  strength.  At  the  end  of  this  period  of 
improvement,  however,  she  suddenly  failed,  and  died  two  weeks 
after  the  return  of  her  symptoms. 

Vomiting  in  Cancer. — Vomiting  is  one  of  the  commonest  symptoms 
of  gastric  cancer,  occurring  in  80  per  cent,  of  the  hospital  series  and 
in  05  per  cent,  of  the  writer's  jjrivate  cases.  Tt  is  probable  that  this 
difference  is  due  to  the  fact  that  the  private  cases  are  seen  earlier  in 
their  course,  are  more  carefully  treated  at  the  outset,  and  that  dietetic 
restrictions  are  more  conscientiously  carried  out. 

The  most  freciuent  time  for  vomiting  is  after  meals,  the  period  vary- 
ing from  a  few  minutes  to  several  or  more  hours.  Cancers  at  or  near 
the  cardia   ahnost   regularly  cause  earlier  vomiting  after  meals  than 


SYMPTOMS  OF  CANCER  229 

those  of  the  body  of  the  stomach,  while  in  cancer  of  the  pylorus,  late 
vomiting,  with  all  the  characteristics  of  gastric  stagnation,  is  the  rule. 

As  in  the  case  of  gastric  ulcer,  although  the  time  after  meals  at  which 
vomiting  occurs  varies  in  the  diii'erent  patients,  yet  each  patient  has 
his  own  period  of  time  at  which  he  is  apt  to  suffer  from  his  vomiting. 
In  gastric  cancer,  however,  this  rule  is  not  as  sharply  defined  as  in  ulcer, 
the  vomiting  in  many  cases  being  more  irregular  in  type. 

The  vomiting  in  cancer  is  not  as  frequently  followed  by  relief  to  the 
pain  as  is  the  case  with  vomiting  in  ulcer.  The  cancer  vomiting  is 
usually  preceded  by  uneasiness  and  nausea,  which  may  be  relieved  by 
the  emptying  of  the  stomach,  but  some  degree  of  pain  is  exceedingly 
apt  to  persist.  For  this  reason  induced  vomiting  is  rare  in  cancer  as 
compared  wdth  ulcer.  In  a  certain  number  of  cases  the  pain  is  worse 
after  vomiting  than  it  was  before. 

When  vomiting  once  occurs  it  is  more  apt  to  be  a  prominent  symptom 
than  in  ulcer,  not  only  more  frequent  in  its  occurrence,  but  more  con- 
tinuous, and  lacking  the  periods  of  intermission  or  remission  so  com- 
monly' seen  in  ulcer.  It  is,  moreover,  less  amenable  to  dietetic  treat- 
ment than  in  ulcer.  Few  ulcer  cases  vomit  after  a  few  days  of  milk 
diet  and  alkalies,  whereas  in  cancer,  the  vomiting  frequently  persists 
no  matter  how  carefully  the  patient  is  treated.  The  vomiting  in  cases 
of  involvement  of  the  pylorus  is  usually  more  pronounced  a  symptom 
than  in  cancers  situated  elsewhere  in  the  stomach.  Cessation  of  the 
vomiting  may  occur  in  these  cases,  due  to  the  ulceration  of  the  occluding 
growth  and  consequent  enlargement  of  the  pyloric  orifice,  or  in  rarer 
cases  from  the  establishment  of  a  gastrocolic  fistula. 

In  many  cases  the  disease  first  manifests  itself  by  acute  and  severe 
vomiting.  With  or  without  the  history  of  a  preceding  dietetic  indis- 
cretion, the  patient  is  seized  by  the  uncontrollable  vomiting  of  what- 
ever is  taken  into  the  stomach,  and  for  days  or  weeks  is  unable  to  retain 
anything.  In  a  large  number  of  these  cases,  diarrhea  may  occur  with 
the  onset  of  vomiting,  so  that  the  case  closely  resembles  acute  gastro- 
enteritis. The  diagnosis  of  these  cases  is  often  one  of  the  greatest 
difficulty.  It  is  well  in  this  connection  to  remember  that  the  vomiting 
of  acute  gastritis  seldom  lasts  more  than  two  or  three  days,  and  is 
usually  amenable  to  dietetic  treatment,  whereas  the  vomiting  of  this 
group  of  cancer  cases  may  continue  for  days  or  weeks  and  is  not  apt 
to  be  materially  relieved  by  careful  dieting.  A  close  questioning, 
moreover,  of  the  cancer  cases,  will  usually  bring  out  the  fact  that  the 
patient  had  been  losing  flesh  and  complaining  of  some  indefinite  symp- 
toms of  indigestion  prior  to  the  acute  onset. 

J.  P.,  aged  forty-two  years,  entered  the  hospital  August  9,  1907. 
Patient    has  been  a  steady  drinker  of    beer,   and    in    addition    goes 


230  CANCER  OF  THE  STOMACH 

on  fretjueiit  sprees.  Was  well  until  two  months  ajjo,  when  he  was 
sick  with  "some  stomach  tr()ul)le.  "  This  occurred  after  one  of  his 
sprees  and  he  does  not  remember  very  much  about  the  symptoms 
at  that  time.  Six  weeks  ago  he  was  suddenly  seized  with  nausea, 
vomiting,  and  diarrhea.  Since  that  time  he  has  been  able  to  retain 
but  little  on  his  stomach,  as  he  vomits  as  soon  as  food  is  taken,  the 
\omited  matter  being  green  and  offensive.  The  stools  have  been 
profuse,  frequent,  and  watery,  but  he  has  lost  no  blood  either  in  the 
vomited  matters  or  by  the  bowels.  He  thinks  that  in  the  past  three 
months  he  has  lost  about  30  pounds. 

Physical  examination:  Man  of  medium  frame,  greatly  emaciated, 
somewhat  cachectic.  There  are  a  few  fine  rales,  slight  dulness,  and 
prolonged  expiration  at  the  right  apex  posteriorly.  His  patellar  re- 
flexes were  not  obtained.  A  distinct  hard  nodular  mass  but  slightly 
movable  is  distinctly  palpable  in  the  epigastrium.  Vomited  matters 
consist  of  a  brownish  fluid,  together  with  small  quantities  of  blood 
without  hydrochloric  acid,  or  lactic  acid.  Patient  lived  fifteen  days 
after  admission  vomiting  all  food  or  medication  given  by  mouth,  and 
annoyed  by  a  persistent  diarrhea.  He  had  no  pain  or  other  gastro- 
intestinal symptoms.     Death  occurred  from  progressive  weakness. 

Character  of  Vomited  Matter. — The  character  of  the  vomited 
matters  vary  greatly,  depending  upon  the  size  of  the  growth,  the  pres- 
ence of  retrograde  changes,  such  as  ulceration  or  sloughing  of  the  mass, 
and  upon  the  patency  of  the  gastric  orifices.  In  the  majority  of  cases 
the  vomited  matters  consist  chiefly  of  food  recently  taken  admixed 
with  mucus,  and  do  not  differ  materially  from  those  observed  in  acute 
gastritis,  except  that  the  vomiting  extends  over  a  longer  period  of 
time.  In  other  instances  the  correct  diagnosis  is  at  once  suggested  by 
evidences  of  food  stasis  in  the  vomited  matters,  and  by  the  presence 
of  Oppler-Boas  bacilli  and  of  altered  blood. 

The  vomited  matters  may  be  of  a  putrefactive  or  gangrenous  odor, 
suggestive  of  the  sloughing  of  the  cancer  mass.  In  rarer  instances  the 
vomited  matters  may  be  fecal  or  of  a  distinctly  fetulant  odor.  This 
type  of  vomiting  usually  occurs  with  gastrocolic  fistula  or  with  the 
patulous  rigidity  of  the  pylorus.  It  has  l)een  also  observed  with  a  com- 
plicating intestinal  obstruction  or  with  peritonitis  either  suppurative 
or  malignant. 

In  1(1  ])cr  cent,  of  the  private  cases  there  occurred  occasional  attacks 
of  the  vomiting  of  large  quantities  of  brown  acid  fluid,  usually  of  high 
hydrochloric  acidity,  although  the  acidity  may  be  low.  These  cases 
closely  resemble  those  of  ulcer  with  hypersecretion,  and  from  them  a 
diagnosis  may  at  first  be  impossible. 

It   is  interesting  that  only  one  of  the  hospital   series  show(>(l   this 


SYMPTOMS  OF  CANCER  231 

peculiar  form  of  vomiting,  and  tlu;  only  explanation  for  the  apparent 
rarity  of  this  type  of  vomiting  is  in  the  fact  that  the  patients  are  dis- 
charged, with  the  diagnosis  of  gastric  ulcer,  owing  to  the  widespread 
misapprehension  that  gastric  cancer  is  not  apt  to  be  found  in  cases 
which  show  high  hydrochloric  acidity. 

In  one  case  observed  by  the  writer  copious  fluid  vomiting  containing 
lactic  acid,  but  no  hydrochloric  acid,  occurred  in  a  patient  during 
apparently  robust  health. 

L.  T.,  aged  forty  years,  previous  history  unimportant.  Had  never 
complained  of  indigestion  until  five  weeks  before  his  death,  when  after 
playing  golf  all  the  morning  he  ate  a  hearty,  hasty  lunch,  and  played 
the  remainder  of  the  afternoon.  Following  this  he  complained  of  a 
slight  sense  of  fulness  in  the  stomach  after  eating  for  several  days, 
and  then  remained  well  and  strong,  eating  everything  without  dis- 
comfort. 

Gastric  analysis  at  this  time  showed  fasting  stomach  contains  22  c.c. 
brownish  fluid,  total  acidity  42,  free  hydrochloric  acid  26.  No  lactic 
acid,  sarcinse,  or  Oppler-Boas  bacilli.  Blood  positive.  Test  breakfast 
125  c.c,  well  digested.    Total  acidity  20,  free  hydrochloric  acid  10. 

He  continued  thus  until  twelve  days  before  his  death,  when  he  had 
a  severe  gastric  hemorrhage,  and  at  the  same  time  felt  a  mass  in  his 
stomach  which  he  says  was  not  there  before. 

Physical  Examination. — A  large,  well-developed  man  of  normal 
healthy  appearance,  denying  any  loss  of  weight.  Lying  transversely 
across  the  abdomen  on  the  umbilical  level  is  a  mass  extending  one 
inch  to  the  right,  two  inches  to  the  left,  hard,  insensitive,  freely  mov- 
able and  capable  of  expiratory  fixation.  The  entire  umbilical  pit  is 
infiltrated  and  of  a  stony  hardness. 

He  was  at  once  put  on  a  rigid  ulcer  treatment.  On  the  fourth  day  of 
his  starvation  he  vomited  82  ounces  of  brownish  offensive  fluid,  although 
the  total  liquids  taken  in  the  four  days  amounted  to  only  20  ounces. 
Total  acidity  56,  no  free  hydrochloric  acid,  lactic  acid  strongly  positive. 
Blood  reactions  well-marked. 

This  vomiting  continued,  though  not  exceeding  16  to  24  ounces  a  day, 
in  spite  of  rectal  alimentation. 

After  consultation  with  the  late  W.  T.  Bull,  it  was  decided  to 
perform  gastro-enterostomy,  which  was  done  on  the  tenth  day  of  his 
medical  treatment.  Although  the  stomach  had  been  emptied  the  pre- 
\ious  night  and  the  patient  had  not  partaken  of  any  food  or  liquid 
during  the  night,  there  were  drained  from  the  stomach  the  morning 
of  the  operation,  11  pints  of  the  same  blood-stained,  oft'ensive  liquid, 
rich  in  lactic  though  lacking  in  free  hydrochloric  acid.  The  patient 
died  the  day  after  the  operation. 


232  CANCER  OF  THE  STOMACH 

Autopsy  showed  a  cancerous  tumor  the  size  of  a  small  orange  com- 
pletely surrounding  the  pylorus,  and  causing  an  extreme  degree  of 
stenosis  of  that  orifice.  The  stomach  was  moderately  dilated,  its  walls 
were  thin  and  contained  a  few  secondary  nodules  along  the  line  of  both 
upper  and  lower  cur\'ature.  A  cancerous  nodule  was  found  in  the 
umbilical  pit,  but  no  other  metastases  were  present.  The  wound  was 
clean  and  aseptic. 

In  cases  in  which  there  is  diffuse  cancerous  infiltration  of  the  stomach, 
causing  a  general  thickening  of  its  walls  with  a  somewhat  diminished 
lumen,  the  so-called  "water-bottle  stomach"  or  the  cancerous  form  of 
linitis  plastica,  vomiting  is  often  characteristic.  Emesis  occurs  soon 
after  eating  and  in  small  quantities,  as  if  the  stomach  could  hold  only 
a  small  amount  of  food  at  any  one  time.  It  is  especially  characteristic 
for  the  ^•omiting  to  depend  more  upon  the  quantity  than  upon  the 
quality  of  the  food,  for  if  more  than  a  certain  amount  be  taken  it  is  at 
once  rejected.  Osier  has  called  special  attention  to  these  cases,  which 
in  his  experience  are  far  from  uncommon. 

Hemorrhages  in  Cancer. — Hemorrhages  from  the  stomach  in  gastric 
cancer  may  be  divided  into  two  groups,  visible  and  occult,  these 
two  varieties  having  exactly  the  same  significance,  differing  only  in 
degree. 

Visible  hemorrhage  occurs  in  25  per  cent,  of  cases,  varying  in  quan- 
tity' from  the  vomiting  of  coffee-ground  material  to  a  profuse  or  even 
fatal  hematemesis.  In  the  majority  of  cases  the  bleeding  is  slight, 
differing  thus  from  the  classical  hematemesis  of  ulcer.  The  vomiting 
of  brown  fluid  of  acid  reaction  has  been  alluded  to  under  the  heading  of 
vomiting.  The  blood  may  not  be  vomited,  but  may  pass  in  the  bowel, 
giving  rise  to  black,  tarry  stools.  In  a  small  number  of  cases  a  large 
hematemesis  may  be  the  first  sign  of  the  presence  of  the  growth. 

M.  C,  aged  forty-four  years.  Patient  has  been  in  the  habit  of  taking 
three  or  four  drinks  of  whisky  before  breakfast  and  the  same  number 
throughout  the  remainder  of  the  day,  besides  several  glasses  of  beer 
daily.  Until  onset  of  present  illness  has  never  had  a  day's  sickness 
that  he  can  remember. 

Three  months  before  admission  to  the  hospital  he  suddenly  xoniited 
seveml  cupfuls  of  bright  red  blood.  The  following  day  he  was  seized 
with  a  dull,  aching  pain  in  the  epigastrium,  which  was  constant  and 
progressively  more  and  more  severe  and  he  has  grown  exceedingly 
weak.  ¥oT  the  past  month  he  has  not  been  able  to  retain  any  food  or 
liquid  on  his  stomach  except  milk  taken  in  very  small  quantities  at  a 
time.     No  blood  in  vomitus  since  outset.     Has  lost  much  weight. 

Phiisiml  Examination,  Man  of  medium  frame,  much  emaciated, 
l(Kiks  ill,  and  very  weak.     There  is  slight  rigidity  in  the  ej)igastrium. 


SYMPTOMS  OF  CAACER  233 

In  the  left  upper  quadrant  is  a  tender  mass,  extendin":  2  or  3  inches 
beyond  the  free  border  of  the  ribs,  freely  movable  with  respiration. 
Liver  and  spleen  not  palpable.  No  other  abnormalities.  Test  break- 
fast, total  acidity  10,  no  free  hydrochloric  acid,  no  lactic  acid,  blood 
or  Oppler-Boas  bacilli. 

Blood  Examination:  Red  blood  cells,  3,192,000;  hemoglobin,  35  per 
cent.;  leukocytes,  12,000;  polymorphonuclears,  95  percent.;  lympho- 
cytes, 5  per  cent. 

Urine  examination  shows  faint  trace  of  albumin,  many  hyaline  and 
granular  casts. 

Death  occurred  eight  days  after  admission  to  the  hospital  from  general 
exhaustion. 

It  would  be  difhcult  at  the  onset  of  such  a  case  to  exclude  esophageal 
varices  resulting  from  cirrhosis  of  the  liver. 

The  detection  of  occult  bleeding  either  in  the  gastric  contents  or  in  the 
stools  has  risen  to  importance  only  during  the  past  few  years,  and  is  of 
special  value  in  the  recognition  of  latent  cases  of  cancer  and  ulcer  as  it 
serves  to  distinguish  them  from  neuroses  and  other  benign  conditions. 
The  value  of  the  presence  of  blood  as  a  diagnostic  feature  depends  upon 
the  care  with  wdiich  other  sources  of  bleeding  are  excluded. 

A  positive  blood  reaction  in  the  gastric  contents  not  infrequently 
occurs  in  normal  cases  from  the  slight  traumatism  caused  by  the  passage 
of  a  stomach-tube,  no  matter  how  soft  and  pliable  it  may  be,  nor  with 
what  apparent  ease  it  is  passed.  Blood  in  the  vomited  matter  may 
arise  from  the  stomach  or  pharynx  as  the  result  of  the  muscular  effort 
of  vomiting.  A  positive  test  is  not  of  value  if  rare  meat  or  beef  juice 
has  recently  been  ingested. 

For  the  detection  of  blood  in  the  stools  even  greater  precautions  should 
be  taken  to  avoid  error,  as  the  sources  for  the  bleeding  are  numerous. 
The  technique  and  the  sources  of  error  in  the  test  for  occult  blood  both 
in  the  vomited  matters  and  in  the  stools  are  given  under.  Ulcer. 

Of  the  75  per  cent,  of  the  writer's  patients  with  cancer  who  gave  no 
definite  history  of  hemorrhage,  60  per  cent,  gave  a  positive  blood  reac- 
tion in  the  gastric  contents.  In  many  of  these  cases  only  one  examina- 
tion was  made,  and  it  is  probable  that  repeated  examinations  Avould 
show  that  almost  every  patient  with  gastric  cancer  will  give  from  time 
to  time  evidences  of  occult  bleeding. 

The  frequency  of  occult  blood  in  the  stools  is  equally  as  high  as  that 
in  the  gastric  contents. 

Positive  reactions  were  found  by  the  writer  in  nearly  every  ease  of 
cancer  observed  in  which  repeated  examinations  for  occult  blood  were 
made.  The  remarkable  frequency  of  positive  reactions  has  been  found 
by  other  writers.     In  12  cases  enumerated  h\  Hale  White  10  gave 


234  CANCER  OF   THE  STOMACH 

steadily  positixe  results,  2  ,<,^;i\'e  reactions  from  time  to  time.  .loaeliim 
found  p()siti\e  reactions  in  1 7  out  of  IS  cases,  while  Hartman  had  positive 
results  ill  14  out  of  17  eases.  Boas  found  })ositive  reactions  in  107  out 
of  128  cancer  patients. 

The  practical  rule  should,  therefore,  be  to  make  frequent,  even  daily 
examinations  of  the  stools  of  those  whose  clinical  history  is  suspicious 
of  cancer,  as  well  as  in  those  patients  of  adult  years  who  without 
adequate  cause  become  anemic  and  lose  flesh  and  strength. 

It  must  further  be  emphasized  that  in  every  ulcer  cure,  even  when 
the  diagnosis  of  simple  ulcer  seems  evident,  not  one,  but  a  series  of 
such  examinations  should  be  made,  and  further,  that  in  such  a  case 
recurring  positive  blood  reaction  in  the  stools  during  the  milk  diet 
period  of  the  ulcer  cure,  especially  if  accompanied  by  a  continuance 
of  gastric  discomfort  should  seriously  suggest  the  advisability  of  an 
exploratory  laj^arotomy.  These  points  are  well  brought  out  in  the 
following  history : 

W.  L.,  aged  thirty-five  years,  was  well  until  one  year  ago.  He  then 
began  to  suffer  from  gnawing  pain  in  the  epigastrium  two  hours  after 
eating,  relieved  by  eating  or  else  gradually  wearing  away.  Four  weeks 
ago  he  vomited  a  small  quantity  of  blood.  No  other  vomiting  attacks 
have  occurred  during  his  illness.  Aside  from  a  tender  spot  below  the 
ensiform,  the  physical  examination  is  normal.  His  gastric  analysis 
shows  the  fasting  stomach  empty,  test  breakfast  normal  except  for  a 
slight  increase  in  its  total  acidity.  He  was  put  on  the  von  Leube  ulcer 
cure  and  it  would  have  been  considered  that  the  results  were  favorable 
except  that  he  remained  slightly  anemic  and  the  stools  on  a  milk  diet 
showed  positive  reaction  for  occult  blood.  No  improvement  being 
noted  within  the  first  month  of  his  treatment,  an  exploratory  laparotomy 
was  done,  and  a  carcinoma  ulcerated  on  its  surface  was  found  in  the 
lesser  curvature,  not  involving  the  pylorus.  This  growth  was  inoperal)le. 
Death  occurred  five  months  afterward  from  hemorrhage. 

General  Symptoms. — One  of  the  most  significant  signs  of  the  be- 
ginning of  cancer  of  the  stomach  is  a  loss  of  appetite,  especially  for 
meats  and  other  albuminous  food,  which  may  appear  suddenly,  and 
which  often  is  so  extreme  that  the  patient  has  a  positive  abhorrence 
of  all  kinds  of  food.  This  symptom  a])pearing  in  a  patient  of  cancerous 
age  who  has  pre\iously  paid  little  attention  to  his  stomach  should 
never  be  lightly  cast  aside,  but  should  call  for  an  examination  of  the 
stomach,  both  in  the  fasting  and  in  the  digestive  state.  The  appe- 
tite ma\-  improve  with  careful  dietetic  treatment  of  the  patient  or  by 
judicious  lavage,  and  is  apt  to  return  after  gastro-enterostomy  or  even 
after  a  simple  ex|)loration.  There  are  cases  of  cancer  that  run  their 
course  throughout  with  a  normal  or  excessive  desire  for  food.    In  many 


SYMPTOALS  OF  CANCER  235 

instances,  esj)e('ially  when  a  gastric  analysis  siiow  a  liydrocliloric 
hy})ersccreti()n,  tiic  ])aticnt  may  he  constrained  l)y  reason  oF  the  (hs- 
comfort  to  eat  every  few  hours,  as  if  lie  were  sufi'ering  from  a  dnodcnal 
ulcer. 

Blood. — Anemia  is  a  symptom  common  to  the  majority  of  cases  of 
carcinoma,  although  when  there  has  been  considerable  loss  of  fluid 
by  vomiting  or  a  decrease  in  the  intake  of  liquids,  the  blood  becomes 
somewhat  concentrated  and  may  show  a  normal  or  an  increased  num- 
ber of  red  blood  cells,  with  an  increasing  high  hemoglobin  percentage. 
In  the  majority  of  cases  chloranemia  is  present.  The  number  of  red 
cells  noted  in  the  writer's  cases  is  shown  in  the  following  table  of 
percentage : 

Under  1,000,000 1.8  per  cent. 

1,000,000  to  1,500,000 7.0  per  cent. 

1,500,000  to  2,000,000 3.6  per  cent. 

2,000,000  to  2,500,000 10.0  per  cent. 

2,500,000  to  3,000,000 10.0  per  cent. 

3,000,000  to  3,500,000 26.0  per  cent. 

3,500,000  to  4,000,000 3.6  per  cent. 

4,000,000  to  4,500,000 19.0  per  cent. 

4,500,000  to  5,000,000 10.0  per  cent. 

Over  5,000,000 8.7  per  cent. 

The  hemoglobin  is  relatively  lower  than  is  the  reduction  in  the  number 
of  the  red  cells,  so  that  the  color  index  ranges  between  0.5  and  0.7. 
This  is  an  important  point  in  the  differential  diagnosis  between  cancer 
and  pernicious  anemia,  as  in  the  latter  disease  we  have  a  higher  color 
index  and  a  greater  reduction  in  the  number  of  the  red  cells.  The  usual 
count  in  carcinoma  is  between  2,500,000  and  3,500,000,  rarely  under 
2,000,000,  whereas  in  pernicious  anemia  counts  of  less  than  1,500,000 
are  not  unusual.  It  has  been  said  that  in  carcinoma  red  cells  do  not 
fall  below  1,500,000.  Five  of  the  writer's  cases  disproved  this  statement. 
The  following  are  the  figures: 

Cases.  Number  of  red  cells.  Hemoglobin. 

1 400,000  20  per  cent. 

2  .      . 1,200,000  18  per  cent. 

3 1,280,000  16  per  cent. 

4 1,292,000  20  per  cent. 

5 1,345,000  18  per  cent. 

In  cancer  the  count  is  not  as  low  as  would  be  supposed  judging  from 
the  appearance  of  the  patient.  We  may  have  a  fair  blood  count  with 
an  anemia  and  cachectic  appearance.  The  diminution  of  the  red  cells 
does  not  keep  pace  with  the  cachexia,  whereas  in  pernicious  anemia  the 


236  CANCER  OF  THE  STOMACH 

cachexia  does  not  keep  pace  with  the  diminution  of  the  red  cells.  In 
doubtful  cases  ophthalmic  examination  may  be  of  service,  as  punctuate 
retinal  hemorrhages  are  very  infrequently  found  in  cancer,  while  they 
are  quite  common  in  pernicious  anemia. 

Failure  in  Nutrition. — Failure  in  nutrition  may  be  an  early  and  sugges- 
tive symptom,  and  is  especially  marked  when  the  cancer  in^'olves  either 
orifice  of  the  stomach.  In  the  extraostial  form  when  neither  orifice 
is  obstructed,  changes  in  nutrition  are  less  marked.  In  many  instances 
even  of  pyloric  cancer  remarkable  gain  in  weight  has  followed  careful 
attention  to  the  patient's  diet  or  the  judicious  washing  of  the  stomach. 
Improvement  in  weight  and  in  general  nutrition  usually  occurs  after 
gastro-enterostomy,  or  may  even  follow  a  simple  exploration  of  any 
nervous  or  physical  shock.  The  gain  in  weight  in  such  postoperative 
cases  may  be  very  considerable,  occasionally  amounting  to  50  to  60 
pounds.  A  sudden  increase  in  weight,  without  any  change  in  the 
patient's  treatment,  or  any  other  obvious  reason,  may  indicate  eflfusion 
of  fluid  into  the  pleural  or  peritoneal  cavity  or  a  rapid  invasion  of  the 
liver.  Unexplained  loss  of  weight  with  failure  in  the  appetite  of  those 
of  cancer  age  which  cannot  be  satisfactorily  explained,  should  excite 
our  suspicions  of  the  beginning  of  malignancy. 

Fever. — Fe^'er  is  present  in  about  one-half  the  cases  at  some  time 
or  another  during  their  clinical  course.  The  temperature  curve  may 
show  marked  irregularity,  the  fever  may  be  low  and  continuous  or 
there  may  be  sudden  high  elevations  to  104  or  105  of  short  duration 
for  which  no  cause  can  be  ascribed.  In  other  cases  the  temperature 
may  assume  an  intermittent  curve,  the  elevations  being  preceded 
by  chills  and  followed  by  sweating,  resembling  the  temperature  chart 
of  malaria  or  of  septic  absorption.  The  rise  of  temperature  in  cancer 
may  be  due  to  septic  absorption,  appearing  as  a  late  event  during 
the  cachectic  period,  or  it  may  indicate  the  presence  of  complications, 
of  which  bronchopneumonia  is  perhaps  the  most  common. 

Many  of  these  high  temperatures  in  late  cancer  may  be  explained 
by  the  finding  at  autopsy  that  the  stomach  has  perforated  and  formed 
a  false  communicating  cavity  limited  by  some  of  the  adjacent  structures. 

Pruritus. — Pruritus  is  often  severe,  and  itching  of  the  skin  in  elderly 
people  who  show  no  albumin  or  sugar  in  the  urine  should  excite  our 
suspicions. 

Urine. — The  urine  is  frequently  diminished  in  amount,  owing  to  the 
frequent  vomiting,  and  to  the  diminished  intake  of  foods  and  liquids, 
and  is  most  marked  in  cases  of  pyloric  obstruction.  In  about  one- 
quarter  of  the  cases  the  urine  contains  albumin  in  small  quantities 
and  may  occasionally  give  the  reaction  for  albumose.  The  ethereal 
sulphates  and  indican  are  usually  increased.     In  ])atients  with  pyloric 


SYMPTOMS  OF  CANCER  237 

obstruction  who  secrete  from  the  stomach  lar^e  quantities  of  Hquid 
which  is  either  vomited  or  drained  throucrh  the  tube  and  in  those  cases 
in  which  an  insufficient  quantity  of  food  results  from  their  disease, 
acetone  and  diacetic  acid,  as  in  all  starvation  cases,  may  be  present 
in  the  urine. 

Coma. — The  sudden  onset  of  coma  \^'ith  heart  weakness,  the  so-called 
"coma  carcinomatosum,"  is  a  rare  terminal  event  in  the  course  of  cancer 
of  the  stomach.  Its  exact  cause  is  not  accurately  known,  although  it 
is  supposed  to  be  a  form  of  acidosis.  It  may  be  accompanied  by 
tetany. 

Clinical  Types. — It  is  convenient  in  describing  the  clinical  types  of 
cancer  of  the  stomach  to  divide  them  into  four  groups: 

1.  Those  cases  with  predominant  general  symptoms. 

2.  Those  cases  with  predominant  local  symptoms. 

3.  Those  cases  in  which  both  general  and  local  symptoms  are  present, 
comprising  the  great  majority  of  the  cases. 

4.  Those  cases  in  which  the  symptoms  due  to  metastases  predominate. 
I.   Cases  in  Which  General   Symptoms  Predominate,  Local  Symptoms 

Slight. —  Dry  ShriveUed  Type. — While  this  type  may  be  encountered 
in  all  ages,  it  is  far  more  commonly  in  aged  subjects,  and  is  especially 
frequent  in  almshouse  and  asylum  practice.  The  patient  simply 
becomes  more  and  more  run  down  and  debilitated,  and  dies  exhausted 
without  at  any  time  presenting  obvious  symptoms  of  gastric  disease, 
although  careful  questioning  usually  elicits  the  history  of  painful 
dyspepsia  at  some  time  or  another  during  the  course  of  the  disease. 
It  is  not  uncommon  for  the  local  symptoms  to  be  more  marked  at  the 
onset  than  later  in  the  disease  when  the  patient  is  wearied  by  the 
ravages  of  disease.  Physical  examination  may  or  may  not  reveal  the 
presence  of  a  neoplasm,  but  a  contracted  scaphoid  abdomen  can  be 
noted  in  a  sufficient  number  of  cases  to  afford  a  suggestive  clue  to  the 
diagnosis.  Anemia  is  seldom  marked  in  this  group  of  cases,  many 
being  shrivelled  up  subjects  who  give  a  relatively  high  blood  count. 
In  one  dried-up  old  lady  in  the  writer's  care,  the  blood  count  shortly 
before  death  was  red  cells  6,080,000,  hemoglobin  98  per  cent. 

Anemic  Type. — In  other  cases  the  clinical  type  presented  is  one  of 
anemia,  at  first  resembling  ordinary  secondary  chloranemia,  later 
approaching  the  pernicious  form  in  many  of  its  essential  features.  The 
onset  of  an  unexplained  secondary  anemia  in  those  of  the  cancer  age, 
especially  when  associated  with  anorexia  and  loss  of  weight,  should 
excite  apprehension  even  in  the  absence  of  gastric  symptoms  or  definite 
physical  signs. 

Intestinal  parasites  must  be  considered  a  possibility  in  these  obscure 
anemic  cases. 


238  CANCER  OF  THE  STOMACH 

II.  Cases  with  Predominant  Local  Symptoms,  General  Symptoms  not 
Marked. — In  this  group  the  Kical  symptoms  appear  early  and  simulate 
those  due  to  a  variety  of  acute  gastric  disorders.  Boas  estimates  that 
25  per  cent,  of  the  cancer  cases  begin  thus  acutely.  An  abrupt  onset 
is  especially  frequent  in  the  cancer  of  young  subjects.  The  more  careful 
we  are,  however,  in  obtaining  an  accurate  clinical  history,  not  only 
from  the  patient,  but  from  the  family  and  friends  as  well,  the  more 
frequently  do  we  find  that  in  cases  in  which  the  onset  apparently 
begins  with  acute  local  symptoms,  that  there  has  been  a  gradual  loss 
of  flesh  and  an  increasing  deterioration  of  health  prior  to  the  appear- 
ance of  these  abrupt  symptoms. 

In  a  number  of  cases,  however,  which  the  writer  places  at  about 
10  per  cent.,  local  symptoms  are  abrupt  and  severe  without  previous 
appreciable  change  in  the  patient's  general  condition. 

Vomitinci  may  appear  early  and  for  a  considerable  time  may  continue 
to  be  the  only  symptom  of  importance.  In  these  cases,  to  which  refer- 
ence has  already  been  made,  the  diagnosis  is  often  erroneously  made 
of  gastritis.  When  one  reflects,  however,  on  the  relative  infrequency 
of  vomiting  in  gastritis  there  is  little  excuse  for  such  an  error,  in  the 
great  majority  of  instances. 

When  the  vomiting  is  characteristic  of  hi/persecretiou,  however,  the 
difficulties  of  diagnosis  are  much  increased.  Such  an  onset  occurs 
especially  with  pyloric  cancer  and  is  not  uncommon.  The  clinical 
history  closely  resembles  that  of  ulcer.  The  patient  usually  complains 
of  pain  one  or  two  hours  after  eating,  often  relieved  for  a  time  by  eating 
or  by  taking  soda.  From  time  to  time  there  occurs  vomiting  of  large 
quantities  of  acid  fluid,  often  of  intense  IICl  acidity,  as  in  pyloric 
ulcer.  During  the  intervals  of  the  hypersecretion — vomiting,  gastric 
analyses  may  show  evidences  of  food  stagnation,  though  usually  of 
slight  degree.  As  these  symptoms  occur  usually  early  in  the  course 
of  the  disease  the  nutrition  and  strength  are  well  maintained,  and  the 
case  is  regarded  as  ulcer  without  any  suspicion  as  to  its  true  nature. 

The  behavior  of  the  case  during  the  ulcer  cure  usually  indicates, 
however,  that  there  is  something  more  than  a  simple  ulcer  that  we  are 
treating. 

It  should  arouse  our  suspicion  of  malignancy  in  any  case  of  ulcer 
undergoing  treatment, 

1.  If  occult  blood  l)c  present  in  the  stools  during  the  milk  diet 
period  of  the  ulcer  treatment. 

2.  If  pain,  nausea,  or  vomiting  persist  after  the  flrst  ten  days  of  the 
ulcer  cure. 

'A.  If  the  patient  fail  in  strength  or  become  |)rogressi\el\'  anemic 
after  the  second  week,  or  to  lose  weight  in  spite  of  a  sufficient  diet. 


,si'M/^7y;.v/,s'  of  cancer  239 

If  any  of  these  indications  of  malignancy  arise  an  exploration  shoukl 
be  thoroughly  considered.  The  following  case  illustrates  the  foregoing 
points: 

G.  M.,  aged  forty-two  years.  Well  until  nine  months  ago,  when  he 
began  to  complain  of  pain  in  the  epigastrium  two  or  three  hours  after 
eating;  relieved  by  eating.  He  felt  well  otherwise.  Two  months  ago 
he  developed  nocturnal  vomiting,  the  vomited  matter  consisting  of 
food  remains  of  his  dinner,  with  large  quantities  of  fluid  of  an  acid 
taste.     After  vomiting  he  would  feel  absolutely  comfortable. 

Examination  showed  slight  tenderness  at  the  costal  angle. 

Fasting  stomach,  35  c.c.  fluid,  few  starchy  food  remains  found  micro- 
scopically.   Total  acidity  46,  free  hydrochloric  acid  28. 

Test  breakfast,  45  c.c.  well  digested — no  hypersecretion.  Total 
acidity  50,  free  hydrochloric  acid  20. 

The  diagnosis  was  made  of  ulcer  at  the  pylorus,  and  the  von  Leube 
treatment  was  started  January  5.  On  the  third  day  of  total  abstinence 
from  food  and  drink  he  vomited  21  ounces  of  dark  green  fluid,  total 
acidity  74,  free  hydrochloric  acid  56.  On  the  seventh  day  (taking  only 
small  quantities  of  milk  and  vichy)  vomited  8  ounces  of  the  same  acid 
fluid.  On  the  ninth  day,  at  8  p.m.,  vomited  16  ounces  fluid,  total 
acidity  114,  free  hydrochloric  acid  66;  at  10  p.m.,  vomited  15  ounces 
fluid,  total  acidity  98,  free  hydrochloric  acid  58.  At  5  a.m.  the 
following  day  vomited  16  ounces  fluid,  total  acidity  72,  free  hydro- 
chloric acid  54.  From  this  time  on,  under  bismuth  subcarbonate, 
bicarbonate  of  soda  and  atropine  he  had  no  further  vomiting  attacks, 
and  the  distress  in  his  stomach  practically  ceased.  His  stools,  however, 
gave  a  constant  positive  reaction  for  blood,  and  he  continued  to  lose 
weight  in  spite  of  an  adequate  amount  of  food  and  the  most  tonic 
regimen. 

Because  of  the  diminishing  weight  and  the  constant  presence  of  blood 
in  the  stools,  and  a  slight  return  of  gastric  distress  an  exploration  was 
performed  May  4.  A  carcinoma  the  size  of  a  lemon  was  found  at  the 
pylorus  without  evidence  of  previous  ulceration.  There  were  no 
adhesions  and  apparently  no  glandular  involvement. 

In  other  cases  yain  is  an  early  feature  and  may  exist  for  a  considerable 
time  without  other  manifestations  of  disease.  In  these  cases  careful 
examination  should  be  made  for  chronic  appendicitis,  for  concealed 
hernia,  for  epigastric  hernia  of  the  linea  alba,  and  for  disease  of  the 
gall-bladder.  The  diagnosis  from  the  visceral  pain  of  arterial  sclerosis 
is  frequently  difficult. 

In  rarer  cases  repeated  hemorrhages  may  occur  as  the  only  manifesta- 
tion of  disease,  rendering  a  diagnosis  from  cirrhosis  of  the  Vwer  or  from 
ulcer  almost  impossible. 


240  CANCER  OF  THE  STOMACH 

III.  Cases  Giving  Both  Local  and  General  Symptoms. — ^Although  the 
general  symptoms  are  the  same  in  kind  irrespective  of  the  exact  location 
of  the  growth  in  the  stomach,  local  symptoms  vary  greatly  according 
to  the  location  of  the  part  invoked.    We  distinguish  clinically  between 

1.  Growths  at  the  cardia. 

2.  Growths  at  the  pylorus. 

3.  Growths  not  involving  either  orifices. 

Growths  Involving  the  Cardiac  Orifices. — Painful  digestion  is  a  char- 
acteristic symptom.  The  pain  is  apt  to  occur  at  once  or  very  shortly 
after  eating,  and  is  often  very  intense  and  distressing.  Regurgitation 
of  food  is  not  uncommon,  but  actual  vomiting  does  not  usually  occur. 

The  stomach-tube  is  usually  arrested  at  about  40  to  42  cm.  from  the 
dental  arcade,  its  tip  on  withdrawal  may  be  coated  with  pus  or  blood, 
and  in  the  eye  of  the  instrument  may  occasionally  be  found  fragments 
detached  from  the  neoplasm.  These  signs  and  symptoms  are  indis- 
tinguishable from  those  of  esophageal  cancer. 

Stagnation  of  food  in  the  stomach  does  not  ordinarily  occur  with 
cardiac  growths,  although  should  the  process  extend  below  the  lesser 
curvature,  a  motor  insufficiency  from  "infiltration  rigidity"  may  result. 
In  such  cases,  however,  food  retention  rarely  becomes  a  noticeable 
feature  unless  the  growths  be  sufficiently  widespread  to  involve  the 
pylorus  by  its  extension.  The  position  of  the  tumor  under  the  costal 
arch  renders  it  inaccessible  to  palpation  unless  the  growth  extends  to 
the  lesser  curvature  with  a  downward  or  vertical  displacement  of  the 
stomach. 

Groivihs  at  the  Pylorus. — Pyloric  implantation  is  the  usual  clinical 
type  of  cancer  of  the  stomach,  and  requires  but  a  brief  mention  here 
as  the  symptoms  have  been  previously  described  in  detail. 

Pjdoric  obstruction  is  the  prominent  feature,  vomiting  is  common, 
not  only  of  what  has  recently  been  eaten,  but  of  the  food  that  has 
remained  in  the  stomach  for  an  abnormal  period  of  time,  or  of  the 
copious  acid  fluid  of  the  hypersecretion  type.  The  physical  signs  of  a 
tumor  are  usually  present.  The  diagnosis  of  this  pyloric  type  of  cancer 
is  fraught  with  fewer  difficulties  than  when  the  cancer  is  elsewhere 
situated. 

(Iroirfhs  not  lurolvimj  Either  Orifice. — Extraostial  growths  are 
usually  situated  in  the  lesser  curvature.  Such  a  seat  of  selection  was 
formerly  regarded  as  infrequent,  but  of  late  it  is  thought  that  25 
per  cent,  to  40  per  cent.  (Mikulicz)  of  all  gastric  cancers  arise  in 
this  situation. 

Unless  there  be  extensive  infiltration  of  the  stomach  wall  food-stasis 
does  not  occur.  Rigidity  from  infiltration  may,  however,  allow  of  a 
moderate   motor    iiisufliciciicx .      Should    in\olvement   of   the   pylorus 


METASTASES  AND   INVASION   OF  OTHER    VISCERA  241 

occur,  food-stasis  becomes  evident.  In  cases  of  infiltration  of  the  wall 
of  the  pyloric  antrum,  although  no  actual  distinction  to  the  outward 
passage  of  l)lood  may  exist,  we  have  a  rigid  patency,  as  shown  by  the 
paradoxical  combination  of  pyloric  narrowing  and  of  p}'loric  insuffi- 
ciency. There  may  be  at  the  same  time  food  retention  and  duodenal 
regurgitation.  In  some  cases  of  cancer  of  the  lesser  curvature  cardio- 
spasm may  be  an  initial  symptom,  although  the  cardiac  orifice  is  free 
from  infiltration  by  the  growth. 

The  diagnosis  of  extraostial  cancer  is  often  made  with  difficulty, 
as  the  nutrition  is  frequently  well  preserved  and  the  local  symptoms 
may  lack  definite  and  distinctive  characteristics. 

Those  Cases  in  Which  the  Symptoms  Due  to  Mestastases  Predominate. — 
It  not  infrequently^  happens  that  a  cancerous  peritonitis  with  ascites 
occurs  during  the  course  of  gastric  cancer  and  draws  our  attention  away 
from  the  primary  disease.  The  distention  of  the  abdomen  and  the 
difficulty  in  making  a  thorough  examination  by  reason  of  pain  and 
rigidity  obscure  what  physical  signs  there  might  be  of  gastric  growth. 
Gastric  symptoms  are  present  in  more  or  less  severity,  but  these  may 
be  misinterpreted  as  due  to  the  peritonitis.  It  is  in  these  cases  that 
the  diagnosis  of  tuberculous  peritonitis  is  most  frequently  made.  Less 
frequently  metastases  in  the  lungs  and  pleura  give  a  group  of  predomi- 
nant pulmonary  symptoms.  A  careful  study  of  the  case  should,  how- 
ever, enable  us  to  arrive  at  a  correct  diagnosis.  In  other  cases  gastric 
symptoms  are  not  marked  until  the  advent  of  such  a  complication 
as  extends  to  and  perforates  into  the  colon,  or  a  perforation  of  the 
stomach  wall  with  its  attendant  peritonitis. 

Extensive  deposits  in  the  liver  may  give  the  history  of  cancer  of  the 
liver  with  gastric  symptoms  well  in  the  background.  It  often  happens 
that  when  a  primary  cancer  of  the  stomach  is  complicated  by  metastases 
in  the  liver,  the  growth  of  the  former  becomes  arrested  and  the  symp- 
toms become  relatively  quiescent. 


METASTASES  AND  INVASION  OF  OTHER  VISCERA 

Carcinoma  of  the  stomach  almost  always  extends  beyond  the  con- 
fines of  that  organ  before  death  to  invade  contiguous  or  more  remotely 
situated  parts  of  the  body.  Such  a  secondary  involvement  may  occur 
in  two  ways:  (1)  By  direct  invasion;  (2)  through  the  lymphatic  or 
blood  stream. 

By  Direct  Invasion. — The  growth   may  extend  by  direct  lines  of 
invasion  through  bridges  of  fibrinous  adhesions,  diaphragm,  pancreas, 
colon,  peritoneum,  or  the  abdominal  wall. 
\% 


242 


CANCER  OF  THE  STOMACH 


In  ]'.U  of  Fenwick's  cases: 

Pancreas  directly  invaded  in 
Liver  directly  invaded  in 
Colon  directly  invaded  in 
Spleen  directly  invaded  in     . 
Eso[)hasus  directly  invaded  in 
Duodenum  directly  invaded  in 


16.7  per  cent. 
13.7  per  cent. 

5.3  per  cent. 

3.7  per  cent. 

4.5  per  cent. 

1 . 5  per  cent. 


As  rarities,  direct  implication  of  the  kidney  and  the  siii)rarenal  glands 
have  been  recorded. 


Fig.   42 


.Anatomy  of  thf  .stomaoli  with  special   rcforcnco  to  tlic  liloodvesspls    ami    lympiiatics.     The  arrows 
iiifliratc   tlic  direction   of  the   l.\inpliatic   flow.      (W.   J.    Mayo.      Drawiii;;.-^  In-    Ilorothx-    Petcr.s.) 


Carciiionia  of  the  ])yl()ric  region  rarely  extends  into  the  diiodennni, 
owing  to  the  lack  of  continnity  of  the  snhnincous  and  nins(  iilar  coats 
at  the  line  of  fusion,  whereas,  growths  at  the  cardia  are  prone  to  spread 
to  the  walls  of  the  esophagus. 

Infiltration  occurs  frec|uentl\'  in  the  scars  from  former  operations 
done  for  attcmjjted  relief  of  the  disease.  Of  8  such  scars  in  220  cases 
of  cancer  of  the  stomach  in  the  writer's  series  (>  were  infiltrated. 


METASTASES  AND  INVASION  OF  OTHER    VISCERA  243 

Infection  through  the  Lymphatic  and  Venous  Channels. — This  is 
the  most  common  mode  of  extension  and  is  tiie  method  of  transmission 
by  which  metastases  form  in  parts  of  the  body  that  are  not  directly 
in  contact  with  the  primary  growth  by  a  process  of  embohsm. 

Involvement  of  the  pcrifja.stric  and  retroperitoneal  glands  occurs  in 
85  per  cent,  of  the  cases  according  to  Cuneo,  who  also  states  that  an 
apparently  normal  appearance  of  a  gland  does  not  prove  that  it  is 
innocent  of  malignancy.  This  explains  why  Cuneo's  figures  are  higher 
than  those  of  purely  clinical  observers,  and  for  the  same  reason  they 
are  apparently  more  accurate. 

The  importance  of  this  glandular  metastases  is  well  understood  by 
the  surgeon  of  today  in  his  endeavor  to  remove  these  outposts  of 
malignancy  as  radically  as  is  feasible  at  the  time  of  operation. 

The  svpracJavicidar  glands,  especially  those  located  at  the  junction 
of  the  thoracic  duct  and  vena  cava  are  involved  in  many  cases  and  may 
be  distinctly  enlarged.  Such  a  glandular  enlargement  is  palpable  in 
about  4  per  cent  of  cases,  although  some  observers  make  this  occurrence 
one  of  greater  frequency.  Eichhorst,  for  example,  claims  that  enlarge- 
ment of  the  cervical  glands  occurs  in  21  per  cent,  of  cases  of  cancer 
of  the  stomach.  The  left-sided  glands  are  more  usually  implicated, 
and  it  is  a  common  routine  practice  in  suspected  cases  to  examine 
the  base  of  the  neck,  on  the  left  side  only,  forgetting  that  the  glands 
of  both  sides  are  frequently  involved,  and  occasionally  the  glands  on  the 
right  side  may  alone  be  involved. 

In  17  cases  in  which  the  supraclavicular  glands  were  involved 
Hosch^  reports  that  those  of  the  left  side  were  involved  alone  in  13, 
those  of  both  sides  in  2,  and  those  of  the  right  side  alone  in  2.  In 
doubtful  cases  if  tuberculous  and  syphilitic  adenitis  can  be  excluded, 
this  authority  advocates  excision  of  the  enlarged  gland  for  diagnostic 
purposes. 

In  435  cases  of  upper  abdominal  carcinoma  reported  by  Palmer  of 
the  ]\Iayo  clinic,  there  were  IS  cases  (4  per  cent.)  of  supraclavicular 
gland  enlargement.  One  case  was  right-sided,  one  right-  and  left-sided, 
the  remainder  were  left-sided  alone. 

Other  glands  such  as  the  bronchial  and  mediastinal  may  be  similarly 
affected. 

According  to  Stockton,  of  2156  cases  of  carcinoma  of  the  stomach:- 

The  liver  was  involved  in 33.3  per  cent. 

The  peritoneum  and  intestines  were  involved  in  .      .  27.6  per  cent. 

The  pleura  and  lung  were  involved  in        .      .  7.3  per  cent. 

The  pancreas  was  involved  in 7.6  per  cent. 

1  Mitteil.  a.  d.  Gronzgch.  d.  Mod.  u.  Chir.,  xviii,  Heft  3,  4S9. 


244  CANCER  OF  THE  STOMACH 

According  to  Fenwick,  the  frequency  of  the  rarer  metastases  is: 
kidneys  4  per  cent.,  heart  2.3  per  cent.,  ovaries  2.3  per  cent.,  spleen 
2  per  cent.,  bones  2  per  cent.,  uterus  1.5  per  cent.,  brain  0.7  per  cent. 
Involvement  of  the  brain  is  almost  invariably  associated  with  a  tumor 
of  the  lung. 

The  fact  that  the  veins  of  the  stomach  enter  directly  into  the  portal 
system  is  sufficient  to  account  for  the  inordinate  frequency  of  metas- 
tatic deposits  in  the  liver.  These  vary  greatly  in  size  and  number, 
and  their  de^'elopment  is  often  excessive  when  compared  with  the  size 
of  the  original  tumor.  Fenwick  states  that  metastases  in  the  liver 
occur  with  relative  infrequency  with  cancer  of  the  pylorus  causing 
stenosis  at  that  orifice. 

Ascites  is  not  uncommon  with  cancer  of  the  stomach,  and  was  present 
in  6  per  cent,  of  the  writer's  cases.  The  effusion  may  be  due  to  portal 
congestion  by  pressure  of  enlarged  periportal  glands,  but  the  usual 
cause  is  to  be  found  in  cancerous  peritonitis.  In  one  of  the  writer's 
cases  ascites  was  due  to  subacute  peritonitis  from  the  perforation  of 
the  duodenum  which  had  been  invaded  by  the  extension  distally  of  a 
primary  pyloric  growth.  In  the  ascitic  fluid  cells  showing  well-marked 
mitoses  may  be  found  and  are  of  considerable  importance  in  diagnosis. 
The  possibility  of  an  intercurrent  cirrhosis  of  the  liver  must  be  borne 
in  mind. 

In  a  certain  ])rop()rtion  of  cases  of  cancer  of  the  stomach  portions  of 
the  growth  enter  the  general  peritoneal  cavity,  and  gravitating  down- 
ward, find  points  of  implantation  in  Douglas'  cul-de-sac  on  the  anterior 
surface  of  the  rectum,  usually  3  or  4  inches  from  the  anus.  They  may 
be  single  or  multij)le,  or  they  may  be  fused  to  form  an  area  of  infil- 
tration. Ordinarily  they  do  not  exceed  the  size  of  a  hazel-nut.  They 
are  to  be  distinguished  from  primary  rectal  growths  by  their  implan- 
tation on  the  peritoneal  surface  of  the  bowel  not  involving  the  mucous 
membrane.  In  a  series  of  435  cases  of  upper  abdominal  carcinoma  in 
the  Mayo  clinic,  .307  cases  being  of  carcinoma  of  the  stomach.  Palmer* 
found  that  2S  (G  per  cent.)  showed  secondary  deposits  on  the  rectal 
shelf  or  in  the  cul-de-sac  of  Douglas,  with  but  2  exceptions,  abdominal 
fluid  was  clinically  questionable  or  absent. 

As  a  rule  these  i)clvic  deposits  give  rise  to  no  symptoms.  They 
may  occur  with  latent  carcinoma  of  the  stomach,  and  their  detection 
in  doubtful  cases  ma\  be  of  the  greatest  helj)  in  diagnosis,  hence,  a 
routine  examination  of  the  rectum  should  never  be  neglected.  Not 
only  may  the  detection  of  pelvic  growths  be  of  diagnostic  value  but 
they  may  be  the  earliest  clinical  evidence  of  ino|)erability  as  far  as  a 

'  Surfjcry,  Clynccolofiy,  and  Olistct  rics,  I'chruaiy,  H»10,  p.  1.51. 


PHYSICAL  SKINS   AND   X^ix'AV   I'JX  A  M I  .\  AT  lOX  245 

radical  operation  is  concerned.     It  is  iiiterestin<;-  to  note  that  in  wonien 
metastasis  of  the  ovary  nia\-  occur. 

Fig.  43 


Metastatic  tumor  in  the  rectal  wall. 

Infiltration  of  the  umbilical  ring  occurs  in  a  fair  proportion  of  cases. 
It  is  easily  detected  by  palpation,  is  of  considerable  diagnostic  value, 
and,  moreover,  indicates  inoperable  extension  of  the  disease. 

PHYSICAL   SIGNS    AND    X-RAY   EXAMINATION 

Physical  Signs. — Inspection. — Inspection  gives  information  more  or 
less  suggestive  in  a  little  over  half  of  the  cases  that  are  fairly  advanced. 
As  would  be  expected,  but  little  information  is  to  be  derived  from  this 
method  of  examination  in  the  operable  stage  of  early  cases  in  which 
we  are  most  anxious  to  establish  our  diagnosis.  For  inspection  to  be 
of  any  service,  the  light  must  be  good,  preferably  oblique,  and  the 
abdomen  should  be  sufficiently  exposed. 

(a)  By  inspection  there  may  be  noticed  a  fulness  under  the  left 
costal  arch,  which  does  not  seem  to  be  the  result  of  body  asymmetry. 

(6)  In  other  cases  a  localized  fulness  or  prominence  may  be  seen 
in  the  epigastrium  which  usually  shows  respiratory  excursions.  This 
prominence  may  be  due  to  the  growth  itself  or  it  may  be  caused  by  a 
distended  stomach,  the  result  of  pyloric  stenosis. 


246  CANCER  OF  THE  STOMACH 

(c)  Visible  evidences  of  tumor  occurred  in  42  ])er  cent,  of  Osier's 
cases.  The  writer  has  incomplete  records  of  the  number  of  his  cases 
in  which  the  mass  was  discernible  as  "growths  of  such  size  that  their 
outline  is  visible,  are  more  accurately  detected  by  palpation. 

(d)  Restricted  respiratory  movements  of  the  lower  thorax  and 
upper  abdomen  may  be  noted  in  cases  of  extensive  adhesions. 

(e)  The  most  important  evidence  afforded  by  inspection  is  the  de- 
tection of  visible  peristaltic  waves  in  the  region  of  the  stomach  passing 
from  left  to  right.  In  every  suspected  case  examination  for  signs  of 
increased  peristalsis  should  be  made,  with  a  strong  oblique  light,  and 
a  sufficient  time  should  be  allowed  for  the  inspection,  as  visible  peris- 
talsis may  appear  only  after  considerable  intervals  of  time.  The  exami- 
nation should  be  made  one  to  three  hours  after  meals  wdien  the  stomach 
is  actively  engaged  in  expelling  its  contents.  Peristalsis  was  visible 
in  but  4  per  cent,  of  the  writer's  cases,  differing  materially  from  the 
experience  of  Osier,  for  in  this  writer's  series  vermicular  motions  of 
the  stomach  wall  or  localized  portions  of  it  were  present  in  a  little 
over  30  per  cent,  of  the  cases. 

(/)  A  scaphoid  abdomen  is  frequently  observed  in  advanced  cases 
with  involvement  of  the  peritoneum.  In  cachectic  patients  it  may  be 
a  phenomenon  of  great  diagnostic  value.  Visible  retraction  was  noted 
in  24  out  of  160  hospital  cases  observed  by  the  writer  (15  per  cent.). 
Of  these  a  palpable  tumor  was  present  in  but  12,  showing  that  marked 
retraction  of  the  epigastrium  usually  interferes  with  palpation  of  any 
existing  mass.  If  an  accurate  examination  be  demanded,  the  patient 
should  be  further  examined  in  a  hot  bath  or  during  light  chloroform 
anesthesia. 

((/)  Symmetrical  enlargement  of  the  abdomen  from  accumulations 
of  fluid  was  noticeable  in  7  per  cent,  of  the  writer's  patients. 

Palpation. — (a)  The  chief  physical  sign  is  the  presence  of  a  palpable 
tumor  which  can  be  demonstrated  to  be  of  gastric  origin.  Unfortunately 
not  every  cancer  of  the  stomach,  even  if  it  be  of  considerable  size,  is 
accessible  to  the  palpating  finger.  Owing  to  the  fact  that  only  the  lower 
half  of  the  pyloric  and  central  thirds  the  stomach  come  normally  into 
contact  with  the  abdominal  wall,  growths  only  in  these  situations  are 
l)alpable  from  their  infancy.  Tumors  of  the  cardia,  of  the  fundus, 
or  of  the  posterior  wall  can  rarely  be  felt  until  tJiey  have  attained 
a  considerable  size,  or  unless  by  reason  of  their  situation  they  have 
caused  a  downward  displacement  of  the  stomach.  Tumors  of  the 
pylorus  and  lesser  curvature  which  may  have  contracted  adhesions  to 
the  under  surface  of  the  liver  are  apt  to  escape  detection. 

In  consequence  the  tumor  is  actually  i)alpable  in  a  comparatively 
small  luniibcr  of  cases.     Fenwick  found  a  tumor  in  but  69  per  cent,  of 


PHYSICAL  SIGNS  AND  X~RAY  EXAMINATION  247 

his  cases,  Osier  in  70  per  cent.  In  the  writer's  series  a  palpable  tumor 
was  found  in  but  54  per  cent,  of  the  patients,  these  figures  being  practi- 
cally identical  with  those  of  Graham  and  Guthrie  in  the  Mayo  clinic, 
who  report  palpable  growths  in  53  per  cent,  of  their  cases. 

It  is  often  more  difficult  to  find  a  tumor  at  certain  times  than  at  others, 
either  because  of  variations  in  the  tactus  eruditus  of  the  examiner 
or  l)ecause  of  varied  conditions  of  the  fulness  of  the  stomach  by  food 
or  by  gas.  It  thus  often  happens  that  a  tumor  palpable  one  day  by 
one  examiner  will  elude  detection  shortly  afterward  by  another  equally 
skilled  diagnostician.  Eichhorst,  experienced  diagnostician  as  he  is, 
makes  the  statement  that  he  has  often  treated  a  patient  with  cancer 
in  whom  a  tumor  was  distinctly  palpable,  after  which  there  might 
pass  weeks  or  even  months  during  which  the  most  careful  examination 
yielded  negative  results,  so  that  he  would  often  have  doubted  his 
diagnosis  had  it  not  been  verified  when  the  case  came  to  postmortem. 
There  may  be  a  transmitted  pulsation  from  the  abdominal  aorta,  so 
that  suspicion  of  aneurysmmay  arise.  Gas  may  be  felt  gurgling  through 
the  tumor  should  the  growth  be  at  the  pylorus,  or  a  well-marked"  pyloric 
squirt"  may  be  audible  through  the  stethoscope  over  the  mass. 

An  interesting  table  is  given  by  Fenwick  showing  the  relative  fre- 
quency of  the  difficulties  encountered  in  detecting  an  existing  growth. 


Difficulties  in  Finding  the  Growth  in  50  Cases 

Fluid  in  the  abdomen 38  per  cent. 

Tumor  deeply  seated,  cardia,  fundus,  posterior  wall      .  30  per  cent. 

Tumor  small 20  per  cent. 

Excessive  tenderness 12  per  cent. 


100  per  cent. 


Situation. — Tumors  of  the  stomach,  especially  those  situated  in  the 
cardiac  end,  may  be  found  in  many  portions  of  the  abdomen,  even  in 
the  pelvis  or  one  or  the  other  iliac  fossa.  The  ordinary  situation, 
however,  is  shown  in  the  following  table  from  figures  given  by  Osier 
and  Fenwick  and  from  the  writer's  series. 


Fenwick. 
Per  cent. 

Umbilical  region 37 

Epigastrium 28 

Right  hypochondrium 17 

Left  hypochondrium IG 

Hypogastrium 2 

Left  costal  arch 


Osier. 

Lockwood 

'er  cent. 

Per  cent. 

22 

38 

41 

25 

15 

19 

16 

18 

24S  CAXCER  OF   THE  STOMACH 

Size. — The  tumor  may  vary  in  size  from  a  small,  barely  palpable 
lump  the  size  of  a  horse-chestnut  to  a  large  mass  filling  the  entire  epi- 
gastrium. The  smallest  tumors  encountered  are  usually  those  of  the 
pylorus,  anterior  surface,  or  lower  curvature,  in  the  situations  where 
the  growth  is  apt  to  come  in  direct  contact  with  the  abdominal  wall. 
F^normous  masses  may  be  encountered  when  the  neoplasm  has  involved 
the  greater  part  of  the  stomach,  or  has  invaded  neighboring  parts  by 
direct  contiguity. 

Shape. — The  shape  may  be  oval,  rounded,  tubular,  or  irregular. 
A  general  infiltration  of  the  wall  of  the  stomach  gives  rise  to  a  mass 
which  in  shape  resembles  that  of  the  normal  organ,  the  lower  margin 
of  which  is  more  distinct  in  outline  than  the  upper.  The  tumor  formed 
by  dift'used  infiltrated  cancer  causing  a  contraction  of  the  stomach, 
the  so-called  "water-bottle"  type,  may  be  felt  as  a  narrow  firm  cord, 
resembling  a  sausage  in  shape,  extending  from  l)el()w  the  left  costal 
arch.  It  may  be  mistaken  for  the  thickened  puckered  omentum  of 
chronic  peritonitis,  tumors  of  the  colon,  or  the  lower  edge  of  a  diseased 
liver.  Tumors  of  the  fundus  often  attain  considerable  size  and  pro- 
jecting beyond  the  left  costal  arch  may  so  closely  resemble  enlarge- 
ments of  the  spleen  that  a  differential  diagnosis  by  physical  examination 
alone  cannot  be  made  Three  such  cases  have  lately  come  under  the 
writer's  observation. 

In  a  case  reported  by  Jellett,^  of  a  woman  who  complained  only  of 
])ain  and  swelling  of  the  abdomen,  a  semicystic  tumor  could  be  felt 
about  the  size  of  a  seven  months'  pregnancy  whicii  turned  out  to  be 
a  malignant  tumor  originating  in  the  stomach. 

Density. — The  growth  if  small  may  be  smooth  and  give  the  feeling 
only  of  an  indefinite  solid  body.  The  majority  of  cancers,  however, 
are  irregular  in  shai)e,  show  slight  nodosities  on  the  surface,  and  are 
of  a  characteristic  stony  hardness. 

Motility. — Tumors  of  the  stomach  almost  always  exhil)it  a  certain 
degree  of  motility,  depending  on  their  situation  and  ui)on  the  presence 
or  absence  of  limiting  adhesions.  Tumors  of  the  jnlorus  are  usually 
freely  movable  unless  the  excursion  of  the  growth  is  limited  by  adhe- 
sions to  parts  that  are  fixed.  Xot  all  adhesions  limit  the  motility  of  the 
neoplasm,  for  in  13  cases  reported  by  Osier  in  which  the  mass  moved 
freely  with  rcsj)iration  and  palpation,  adhesions  were  present  in  9. 

Changes  in  the  position  of  the  mass  Tuay  be  due: 

1.  To  changes  in  the  size  and  ])()sition  of  the  stomach  during  diges- 
tion, or  as  the  result  of  inflation. 

2.  To  the  effect  of  rcsi)irat()ry  mo\'cments. 
'A.  To  the  mechanical  effect  of  i)alpation. 

>  Hiitisli  Med.  .lour.,  March  2:^,  1012. 


I'f/YSICAL  SIGNS  AM)   X-RAY   EX  AM  IX  AT  ION  249 

1.  Tumors  are  often  draggefl  (low  ii  wlu'ii  the  stomach  is  full  and  move 
up  when  the  stomach  empties  itself  again.  The  excursions  during  the 
various  stages  of  digestion  may  be  quite  remarkable. 

Inflation  of  the  stomach  with  gas,  either  as  a  result  of  flatulence  from 
natural  causes  or  by  the  artificial  inflation  by  gas  as  a  method  of  exami- 
nation, usually  produces  characteristic  changes  in  the  position  of  the 
growth.  By  inflation  pyloric  cancers  usually  mo\'e  to  the  right  and 
downward,  rarely  to  the  left  and  upward.  Tumors  of  the  lesser  curva- 
ture tend  to  disappear,  because  by  inflation  the  stomach  revolves  on 
its  longitudinal  axis  so  that  the  upper  curvature  looks  more  directly 
backward  and  the  lower  curvature  looks  more  directly  forward. 
Tumors  of  the  greater  curvature  thus  become  more  evident.  If 
adherent  to  the  pancreas  no  change  in  the  position  of  the  mass  is 
apt  to  occur  with  inflation.  It  need  hardly  be  emphasized  that  the 
inflation  of  the  stomach  with  gas  for  diagnostic  purposes  should  be 
done  most  cautiously  to  avoid  perforation. 

2.  Respiratory  movement  is  almost  regularly  present  unless  the  tumor 
be  adherent  to  the  abdominal  w^all  or  pancreas.  In  the  writer's  cases 
42  per  cent.  WTre  freely  movable  on  respiration  or  by  palpation,  12 
per  cent,  w^ere  fixed,  while  no  mention  was  made  of  motility  in  46  per 
cent.  In  Osier's  patients  motility  with  repiration  or  palpation  occurred 
in  60  per  cent.  According  to  Boas,  tumors  of  the  pylorus  do  not  readily 
move  with  inspiration  unless  they  are  adherent  to  the  liver,  w^hereas, 
cancer  of  the  curvatures  shoW',  as  a  rule,  well-marked  respiratory  dis- 
placement. With  this  statement  the  writer  cannot  agree,  as  in  his 
experience  an  equal  motility  in  these  two  situations  has  been  observed. 
It  is  often  difficult  to  distinguish  between  a  respiratory  gliding  of  the 
abdominal  wall  over  a  tumor  and  actual  respiratory  movement  of  the 
tumor  itself. 

3.  Motility  during  palpation  is  usually  evident  to  the  examining 
hand,  and  some  idea  as  to  the  location  of  the  growths  and  the  presence 
or  absence  of  adhesions  may  be  deduced  from  the  extent  of  the 
excursions  of  the  mass. 

^  In  a  certain  number  of  cases  expiratory  fixation  may  l)e  observed. 
This  physical  sign  consists  in  the  grasping  of  the  tumor  during  the 
period  of  deepest  inspiration,  and  preventing  its  ascent  during  expira- 
tion unless  the  grasp  be  released.  Expiratory  fixation  indicates  usually 
the  absence  of  adhesions,  especially  to  the  liver,  but  the  converse  does 
not  always  hold  true.  The  absence  of  expiratory  fixation  does  not 
necessarily  prove  the  presence  of  adhesions. 

Tenderness  to  some  extent  can  almost  invariably  be  elicited  by  deep 
palpation  over  the  diseased  area,  or  of  the  mass  itself.  The  tenderness 
is,  however,  seldom  extreme,  much  less  so  than  in  ulcer,  is  more  diffuse 


250  CANCER  OF   THE  STOMACH 

than  in  the  hitter  disease,  and  is  but  rarely  accomjjanied  by  the  cuta- 
neous hyperesthesia  and  the  dorsal  point  of  tenderness  that  so  often 
occur  with  gastric  ulceration. 

In  many  cases  palpation  yields  only  a  localized  sense  of  resistance, 
especially  in  the  early  cases  before  the  growth  is  large  enough  to  be 
distinctly'  palpable.  Growths  of  the  posterior  wall,  or  those  in  greater 
part  co^'ered  by  the  liver  or  costal  arch,  may  give  only  an  indefinite 
sense  of  resistance  even  though  they  be  actually  of  considerable  size. 

Rigidity  was  appreciable  in  18  out  of  170  cases  in  the  writer's  series 
in  which  mention  is  made  of  its  presence  or  absence  (11  per  cent.). 
Of  these  18  cases  a  tumor  was  palpable  in  5,  and  undetected  in  13,  show- 
ing how  easily  rigidity  of  the  abdominal  wall  may  interfere  with  other 
methods  of  examination.  Rigidity  may  be  localized  in  the  epigastrium 
or  o\'er  the  head  of  either  rectus  muscle,  or  there  may  be  general  ab- 
dominal rigidity,  often  associated  with  a  scaphoid  appearance  of  the 
abdomen. 

Rigidity  indicates  peritoneal  involvement,  and  while  not  especially 
diagnostic  of  cancer,  it  is  a  sign  of  great  importance,  as  it  implies  an 
extension  beyond  the  actual  confines  of  the  stomach  so  as  to  render 
any  hope  for  radical  relief  by  operation  highly  improbable. 

Palpation  may  also  detect  hypertonus  of  the  stomach  in  cases  of 
pyloric  implantation.  With  the  hand  gently  pressing  downward  upon 
the  epigastrium  there  may  be  felt  from  time  to  time  a  sense  of  stiffening 
of  the  stomach  wall,  so  that  the  organ  can  be  quite  readily  mapped 
out.  The  duration  of  the  period  of  stitl'ening  is  usually  quite  short. 
If  the  phenomenon  be  more  pronounced  than  this  there  may  be  felt 
a  marked  prominence  of  the  region  of  the  fundus,  and  at  the  acme  of 
the  contraction  the  i)atient  may  experience  considerable  discomfort,  or 
even  pain.  With  extreme  pyloric  contraction  there  may  be  peristaltic 
waves  passing  from  left  to  right  which  are  distinctly  evident  to  the 
examining  hand.  The  march  of  the  ])eristalsis  is  (juite  stately,  and 
occupies  an  appreciable  period  of  time. 

By  palpation  we  may  make  out  enlarged  supraclavicular  glands 
on  one  or  both  sides  of  the  neck,  infiltration  of  the  nml)ilical  pit,  or 
the  j)resence  of  metastases  in  the  liver  causing  hard  irregularity  of  its 
contour  or  lower  edge.  Rectal  examination  for  the  detection  of  possible 
imi)l!iiitati()ii   in  the  Ncsicorectal  ])()U('h  should  never  ])e  neglected. 

Gastric  Dilatation  with  Cancer. — There  is  considerable  difference 
of  opinion  as  to  the  fr('(|nency  with  whicii  dilatation  of  the  stomach 
accom|)anies  the  i)yloric  stenosis  of  malignant  origin.  Osier  thinks 
that  dilatation  is  relatively  more  commonly  due  to  cancer  than  to  any 
other  cause,  as  in  the  same  period  of  time  he  found  tiiat  of  ()7  cases 
of  dihitatioii    of    the    stoiuaeli    12    were  Aur  to  cancer.     In   his  series 


PHYSIC  A  I.  SIGNS  AND  X-RAY  EXAMINATION  251 

of   If)!)  casi^s  of  cancer  dilatation   cither  before  or  after   inflation  was 
recognizal)le  in  42  instances  (2.S  [)er  cent.). 

On  the  other  hand,  Boas  and  Broadbent  chiini  that  f2;astric  dilatation 
is  not  the  rnle.  The  writer  regrets  that  his  records  are  not  com[)lete 
enough  to  give  statistical  {)r()of  one  way  or  another,  but  is  strongly 
inclined  to  the  belief  that  while  gastric  dilatation  may  occur,  it  is  usually 
to  a  very  slight  degree,  and  that  dilatation,  to  the  extent  that  we  see 
it  with  benign  stenosis,  is  comparatively  rare  except  in  instances  f)f 
carcinomatous  degeneration  of  callous  ulcer  of  the  pylorus. 

X-ray  Examination  in  Cancer. — 1 .  The  .r-ray  examination  of  cancer 
of  the  stomach,  while  usually  convincing  in  cases  of  advanced  growth, 
ma}'  be  totally  inconclusive  in  its  early  stages.  In  some  of  the  early 
cases,  however,  our  suspicions  may  be  aroused  by  certain  deviations 
from  the  normal  in  size,  shape,  and  density  of  the  stomach,  by  distor- 
tion or  by  lack  of  motility.. 

In  some  of  the  early  stages  the  picture  may  resemble  that  of  ulcer. 
Bismuth  residue  after  the  expiration  of  six  hours  indicates  atony  or 
some  form  of  pyloric  narrowing,  either  spasmodic  or  organic,  and  the 
radiographs  of  ulcer  near  the  pylorus,  of  cancer  in  that  vicinity,  and  of 
pylorospasm  accompanying  gall-bladder  or  appendicular  disease,  may 
be  so  similar  that  a  differential  diagnosis  by  this  form  of  examination 
alone  is  quite  impossible. 

In  ulcer  and  cancer  we  may  have  the  same  drawing  of  the  pylorus 
upward  and  to  the  left,  forming  the  "snail-like"  contour  described  in 
ulcer.  xA.ll  we  can  say  is  that  there  seems  to  be  an  organic  pyloric  lesion 
present,  the  exact  nature  of  which  can  only  be  determined  by  the  clinical 
history,  physical  examination,  gastric  analyses,  and  the  clinical  course 
of  the  ailment,  and  possibly  even  then  operation  alone  can  decide. 
The  evidence  of  adhesions  may  be  present  in  both  conditions  (see 
.T-ray  of  ulcer).  According  to  Holzknecht,  a  diagnosis  of  early  carcinoma 
can  be  made  in  a  patient  wdth  achylia,  if,  six  hours  after  the  meal, 
bismuth  residue  is  found  in  the  stomach,  provided  that  the  head  of  the 
bismuth  column  has  at  this  time  reached  the  splenic  flexure,  and  that 
the  second  bismuth  meal  shows  a  normal  stomach  shadow.  Holz- 
knecht's  reasoning  is  that  as  normally  the  head  of  the  bismuth  column 
should  in  six  hours  reach  only  the  hepatic  flexure,  we  are  dealing  with 
hypermotility  when  the  splenic  flexure  is  in  bismuth  shadow,  which, 
when  the  pylorus  is  free,  is  a  regular  accompaniment  of  achylia.  The 
bismuth  residue,  moreover,  demonstrates  an  achylia  with  stagnation. 
The  stipulation  that  the  contour  of  the  stomach  after  the  second 
bismuth  meal  should  be  normal,  would  exclude  atony  and  many  of 
the  cases  of  ulcer. 

It  would  seem  to  the  writer,  however,  that  this  view  of  Ilolzknecht's 


252  CANCER  OF   THE  STOMACH 

is  too  extreme,  as  ulcers  near  the  ijvlorus  which  occasionally  happen 
to  he  associated  with  achylia,  may  i)ro(luce  the  same  radiographic 
picture,  and  that,  furthermore,  a  difterential  diagnosis  from  pyloro- 
spasm  due  to  gall-bladder  disease,  accompanied  as  so  often  is  the 
case,  by  achylia,  would  be  quite  impossible.  Morphinism  must  always 
be  excluded  as  a  possible  cause,  as  in  this  addiction  pylorospasm  and 
bismuth  retention  may  be  found  in  the  stomach,  wdiich,  after  the 
second  bismuth  meal,  is  seen  to  retain  its  normal  size  and  shape,  but 
in  morphinism  there  would  be  no  bismuth  at  splenic  flexure. 

2.  When  cancer  is  so  extensive  and  infiltrating  the  radiograph  may 
show  nodular  indentations  "similar  to  finger  prints"  (Cole),  where 
the  bismuth  shadow  is  not  as  intense  as  elsewhere,  or  does  not  appear 
at  all. 

The  rugie  in  the  infiltrated  area  are  absent. 

When  the  destructive  process  is  extensive,  large  areas  of  the  organ 
may  be  entirely  obliterated,  the  ragged  edge  of  the  uninvolved  area 
sharply  limiting  the  outline  of  the  bismuth  shadow. 

Should  the  pylorus  be  obstructed  by  the  neoplasm,  the  narrow 
constricted  lumen  of  the  pylorus  may  give  passage  to  an  abnormally 
thin  line  of  })ismuth,  which  is  sinuous  and  contorted  in  outline.  Some- 
times the  bismuth  shadow  of  the  pyloric  end  of  the  stomach  narrows 
down  gradually  in  the  form  of  a  cone,  with  a  small  outlet  at  the 
apex. 

In  other  instances  a  thread-like  shadow  may  issue  directly  from  the 
sharply  defined  edge  of  an  apparently  normal  portion  of  the  ])yl()ric 
extremity  of  the  stomach. 

Peristaltic  contractions  become  less  active  upon  entering  the  conical 
area. 

In  some  instances  the  stomach  is  found  to  be  empty  in  six  hours, 
but  has  lost  its  normal  hook  shape,  and  has  assumed  a  "horn  shape," 
being  short  and  placed  diagonally.  It  is  impossible,  how'ever,  by  the 
radiographic  plate  alone  to  determine  whether  this  horizontal,  con- 
tracted stomach  is  due  to  hypertonicity  or  to  infiltration  of  its  wall 
by  cicatricial  tissue  or  by  scirrhus. 

In  cases  of  inoperable  diffuse  carcinoma  of  the  entire  stomach,  in- 
cluding the  cardia,  we  are  apt  to  find  the  stomach  empty  in  six  hours, 
the  head  of  the  bismuth  column  at  or  beyond  the  splenic  flexure,  a 
bismuth  deposit  in  the  lower  esophagus  after  six  hours.  The  second 
bismuth  meal  shows  us  a  greatly  shortened  distorted  organ  lying 
obliquely  in  the  abdomen,  and  the  bismuth  immediately  after  ingestion 
beginning  to  flow  freely  out  of  the  stomach,  indicating  insufficiency 
at  the  pylorus.  The  radiographic  evidence  of  pyloric  stenosis  will  be 
described    under  the  heading  of  pxioric  stenosis. 


PLATE    IV 


Fig.   1 


Fig.    2 


Fig.  1.— Careinonia  of  Body  of  Stomach.  Rigid  Patency  of  Pylorus.  In- 
creased Motility  of  the  Colon,  Head  of  Bismuth  Column  in  Six  Hours 
being  in  the  Descending  Colon.  Fluoroscopic  examination  of  this  ease 
shows  duodenum  filled  with  bismuth  as  far  as  the  duodenojejunal  angle 
■within  ten  minutes  after  the  ingestion  of  tlie  bismuth  meal.  (Radiologist, 
Dr.  Learning.) 

Fig.  2. — Careinon-ia  of  the  Lesser  Curvature,  not  Involving  the  Pylorus. 
(Radiologist,   Dr.   Le  Wald.) 


Fig.  3 


Carcinoma    of    Pyloric     Half    of    the 
Stomach.     (Radiologist,  Dr.  Leaming.) 


Carcinoma   of  the   Pars   Media. 


Fig.  1. — Cancer  of  the  Pylorus  Producing  Stenosis.  Noteworthy  is  the 
undershot  line  of  the  greater  curvature.       (Radiologist,   Dr.   Busby.) 

Fig.  2. — Carcinoma  of  Pylorus,  resembling  Benign  Stenosis.  Stoniach 
dilated  and  displaced.      (Radiologist,   Dr.   Le  Wald.) 


Fig.   S 


Fig.  4 


Fig.  8. — Carcinoma  of  the  Pyloric  End  of  Stoniaeh,  producing  Stenosis. 
(Radiologist,   Dr.    Le  Wald.) 

Fig.  4. — Carcinonia  of  Pylorus,  producing  Tight  Stenosis.  (Radiologist, 
Dr.    L.saming.) 


PLATE    VI 


Fig.    1 


F\,j.    2 


Ficj.  1. — Carcinoma  of  the  Lesser  Curvature,  with  Insufficiency  of  the 
Pylorus.       (Radiologist,    Dr.    Le  Wald.) 

Fig.  2. — Diffuse  Carcinoma  of  the  Entire  Stomach,  with  Insufficiency  of 
the  Pylorus  and  Hypermotility  of  the  Colon.  (Case  of  Dr.  J.  "^JV.  "Weiiistem; 
radiologist,   Dr.   Learning.) 


Fig.  8 


Carcinoma  of  the  Lesser  Curvature.  Deep  incisure  of  greater  curvature, 
resembling  the  incisure  eonimonly  seen  with  ulcer  in  this  situation. 
(Radiologist,    Dr.    Le  ^A;'ald.) 


Carcinoma  of  Lesser  Curvature.  Deep  Broad.  Incisure  in  Greater  Cur- 
vature. The  incisure  in  these  cases  is  apt  to  be  broader  than  is  the  case 
^A/ith  ulcer.       Radiologist,   Dr.   Le  "Wald.) 


Fig.   2 


Ulcer  of  Lesser  Curvature,   eausmg  Spasni  and   Drawing  Up  of 
Greater  Curvature.       (Radiologist,  Dr.    Busby.) 


PHYSICAL  SIGNS  AND  X-RAY  EXAMINATION  253 

In  some  instances  of  cancer  of  the  lesser  ciir\'ature  there  may  be  the 
same  deep  fixed  incisure  as  is  seen  in  ulcer.  In  other  cases  carcinoma 
of  the  greater  curvature  will  produce  the  same  appearance. 

Gastric  Analysis. — It  is  of  the  utmost  importance  to  examine  the 
gastric  contents  in  ever}'  suspected  case  of  cancer,  not  onl}'  to  deter- 
mine if  possible  the  presence  of  the  growth,  but  also  its  situation  with 
reference  to  a  possible  operation.  Every  suspected  case  should  be 
examined,  not  only  once  but  repeatedly,  unless  the  passage  of  a  tube 
be  contraindicated  by  extreme  physical  weakness,  or  by  recent  and 
severe  hemorrhage. 

Examinations  of  test  breakfast  are  commonly  made,  but  the  condi- 
tions of  the  fasting  stomach  have  generally  been  neglected.  The  writer 
believes  that  in  cancer,  examination  of  the  fasting  stomach  gives  as 
important  testimony  of  the  presence  of  a  neoplasm  as  examination 
of  the  test  breakfast,  and  therefore  should  never  be  omitted. 

The  writer's  procedure  in  examining  a  suspected  case  is  as  follows: 

The  patient  eats  during  the  day  his  accustomed  meals.  Between 
10  and  11  o'clock  in  the  evening  he  is  given  a  meat  sandwich,  prefer- 
ably of  cold  roast  beef,  although  any  meat  will  serve  the  purpose,  and 
a  glass  of  water.  Thereafter  nothing  is  to  be  given,  not  even  water, 
imtil  the  following  morning  at  8  to  9  o'clock,  at  which  time  a  stomach- 
tube  connected  with  an  aspirating  bulb  is  passed  and  the  contents 
of  the  stomach  are  withdrawn.  Unless  the  presence  of  appreciable 
quantity  of  fresh  blood  in  the  gastric  contents  or  extreme  physical 
weakness  should  contra-indicate  further  examination,  the  patient  is  to 
be  then  given  a  roll,  without  butter,  and  a  glass  or  water.  One  hour 
after  beginning  such  a  test  meal  the  contents  of  the  stomach  are  again 
withdrawn.  If  food-stasis  is  suspected,  a  tablespoonful  of  raisins  or 
dried  currants  is  given  with  the  evening  sandwich.  For  those  who  find 
the  early  morning  hour  inconvenient,  as  often  is  the  case  with  those 
who  live  out  of  town  and  who  would  therefore  be  compelled  to  travel 
on  an  empty  stomach,  the  following  modification  is  permissible: 

A  breakfast  of  a  small  portion  of  steak,  a  portion  of  boiled  rice  with- 
out sugar  or  milk  or  butter,  and  a  breakfast  roll  are  to  be  given  at  7.30 
A.M.  and  the  contents  withdrawn  four  hours  later,  after  which  the  test 
breakfast  is  to  be  given  as  before. 

In  case  only  one  examination  by  the  tube  is  permitted,  the  steak, 
rice,  and  bread  breakfast  may  be  given  at  7.30,  the  test  breakfast 
given  at  12.30,  and  the  whole  contents  removed  one  hour  later.  A 
rough  estimate  of  gastric  motility  is  aft'orded  by  such  an  examination, 
though  by  no  means  as  exact  as  by  either  of  the  preceding  methods. 

The  writer  has  had  no  occasion  to  use  the  lactic  and  free  oatmeal 
supper  recommended  by  Boas. 


254 


CANCER  OF  THE  ^STOMACH 


By  such  a  double  examinatiou  of  gastric  conteuts,  the  writer  has 
obtaiued  importance  evidence  of  disease  in  So  per  cent,  of  the  cases. 

Examination  of  the  Fasting  Stomach. — Fasting  Stomach  Normal. — 
In  30  per  cent,  of  tiie  patients  examined,  the  fasting  stomach  showed 
absohitely  normal  conditions,  the  proportion  of  such  normal  fasting 
examinations  being  far  greater  in  private  than  in  hospital  practice. 
The  earlier  the  patient  comes  under  observation  the  more  apt  is  the 
fasting  examination  to  approach  the  normal.  The  largest  number 
of  those  with  normal  fasting  conditions  were  found  among  the  cases 
of  cancer  that  did  not  involve  the  patency  of  the  pyloric  orifice.  It  is 
interesting  to  note  that  in  about  one  in  ten  of  these  normal  fasting  cases, 
examination  of  the  test  breakfast  gave  positive  indications  of  organic 
lesion  in  the  stomach.  This  fact  alone  proves  the  importance  of  the 
double  test. 

Fig.  44 


FHStiiiK  contnits  of  Kastric  (•MrciiiDiiia  iin-olviiit;  the  pylorus 


Evidences  of  Motor  Error  in  Fasting  Stomach.  Se\eiity  i)er  cent,  of 
all  patients  with  cancer  of  the  stomach  i)resent  evidences  of  grave 
motor  error  by  the  examination  of  the  fasting  stomach.  Such  evidences 
are  more  commonly  seen  in  h()si)ital  than  in  private  i)ractice.  Seventy- 
eight  per  cent,  of  the  writer's  hospital  cases  gave  evidences  of  food 
stagnation,  whereas  in  onlx-  (il  jxt  cent,  of  the  prixate  cases  could  this 
evidence  be  obtained. 


PHYSICAL  SIGNS  AND  X-RAY  EXAMINATION  2oo 

The  appearance  and  quality  of  the  contents  of  the  fasting  stomach 
indicative  of  stasis,  differ  considerably  in  the  different  cases.  In  some 
instances  there  are  aspirated  small  quantities  only  of  clear  fluid,  con- 
taining food  remains  in  minute  though  in  appreciable  amount.  The 
quantity  of  fluid  varies  from  15  c.c.  to  large  and  copious  amounts,  often 
exceeding  a  liter,  the  quantity  giving  a  fair  estimate  of  the  degree  of 
pyloric  narrowing.  The  fluid  may  be  discolored  by  food  remains  or  by 
altered  blood.  The  aspirated  contents  may  be  clear,  tinged  with  a 
very  slight  sedimentary  layer,  or  may  consist  largely  of  gross  and 
obvious  food  remains.  The  odor  may  be  oflFensive  in  the  extreme  in 
adA'anced  cases  in  which  the  growth  is  ulcerating. 

Chemical  Examination. — The  chemical  examination  differs  in  different 
cases. 

1.  In  18  per  cent,  of  cases  the  fluid  resembles  that  of  ordinary  hyper- 
secretion in  that  it  is  clear  and  is  inoffensive  in  odor.  Food  remains 
are  present  in  varying  amount,  but  the  chief  characteristics  are  those 
of  benign  hypersecretion.  The  quantity  has  varied  in  the  writer's 
case  from  50  c.c  to  500  c.c.  Total  acidity  ranges  between  40  and  120, 
the  acidity  being  due  entirely  to  free  and  combined  hydrochloric  acid. 
In  this  form  lactic  acid  and  the  Oppler-Bcas  bacilli  are  absent.  Sarcinse 
may  be  occasionally  found.  Elccd  is  present  in  small  but  appreciable 
quantities  in  ore-half  the  cases. 

All  the  cancer  patients  in  the  writer's  experience  who  show  this 
form  of  fasting  secretion  are  instances  of  growth  at  the  pylorus.  A 
previous  ulcer  history  is  uncommon,  ncr  in  the  cases  followed  to 
autopsy  were  there  any  obvious  traces  of  former  ulceration. 

2.  In  other  cases  the  gastric  contents  in  the  fasting  state  contain  lactic 
acid.  Thirty-six  per  cent,  of  the  patients  examined  by  the  v\Titer  gave 
this  reaction.  The  quantity  of  aspirated  contents  varied  usually  from 
15  c.c.  to  75  c.c,  but  occasionally  very  large  quantities  could  be  with- 
drawn, in  several  instances  exceeding  2  liters.  Food  remains  are  con- 
stantly present,  and  are  ordinarily  offensive.  The  total  acidity  ranged 
from  30  to  80,  occasionally  higher  than  this.  Lactic  acid  is  distinctly 
present.  Oppler-Boas  bacilli  are  easily  demonstrated.  In  one-quarter 
of  the  cases  giving  lactic  acid  reactions  in  the  fasting  state  free  hydro- 
chloric acid  was  also  present,  and  when  both  hydrochloric  acid  and 
lactic  acid  occur  together,  the  total  acidity  is  usually  high,  in  one 
instance  being  182.  Such  an  analysis  would  seem  to  indicate  a  chronic 
ulcer  at  or  near  the  pylorus  which  has  undergone  carcinomatous 
changes. 

In  three-fourth  of  the  cases  with  lactic  acid  in  the  fasting  contents, 
hydrochloric  acid  is  absent.  The  contents  vary  from  45  to  450  c.c. 
food  remains  are  constantly  present  in  varying  amounts  and  are  fre- 


25fi  CANCER  OF  THE  STOMACH 

quently  offensive.  Gastric  contents  giving  these  reactions  have  been 
found  in  a  Httle  over  25  per  cent,  of  the  writer's  cases. 

3.  There  is  a  group  of  cases  comprising  16  per  cent,  of  the  writer's 
series  in  which  there  are  evidences  of  food-stasis  but  in  which  the  total 
aci(nty  is  so  sHght  as  to  l)e  neghgible.  Both  lactic  acid  and  hydrochloric 
acid  are  absent,  although  in  many  instances  the  Oppler-Boas  bacilli 
are  found.  Blood  is  almost  regularly  present,  often  in  sufficient  quan- 
tities to  neutralize  the  small  degree  of  acidity  that  otherwise  would 
exist.  The  quantity  of  contents  has  varied  in  the  writer's  experience 
from  80  c.c.  to  1000  c.c.  and  is  largely  composed  of  food  remains,  usually 
extremely  foul,  occasionally  even  fetid.  Undigested  meat  fibers  are 
almost  regularly  present.  These  characteristics  of  the  fasting  contents 
afford  conclusive  proof  of  advanced  malignant  disease,  and  occur  with 
sjjecial  frequency  in  hospital  cases. 

To  recapitulate  the  results  of  the  fasting  stomach  examination  in  the 
writer's  series  (224  cases) 

Normal 30  per  cent. 

Stagnation  (a)  With  hydrochloric  acid  alone       ...  18  per  cent. 

(b)  With  lactic  acid 27  per  cent. 

(c)  With  both  lactic  and  hydrochloric  acid  9  per  cent. 

(d)  Without  either  lactic  or  hydrochloric  acid  16  per  cent. 

100  per  cent. 

Of  the  cases  in  which  fasting  contents  were  obtaincrl  (70  per  cent, 
of  the  total  number) : 

Hydrochloric  acid  was  present  alone 2.5.5     per  cent. 

Hydrochloric  acid  was  present  with  lactic  12.9     per  cent. 

Total  percentage  containing  free  hydroch  loric  aciil  .     38.4     per  cent. 

Lactic  acid  was  present  alone 38.67  per  cent. 

Jja(;tic  acid  was  present  witli  hydrochloric;  acid  12,90  per  cent. 

Total  percentage  containing  lai'tic  acid  .       .       .      .      51. .57  ])(>r  cent. 

Trichomonas,  megalostoma  and  various  forms  of  flagellated  infusoria 
may  occasionally  be  found  in  the  fasting  stomach.  They  occur  only  in 
alkaline  or  neutral  media,  and  are  more  common  in  cases  of  carcinoma 
of  the  cardia  or  fundus  without  stagnation. 

Cohnheim  who  has  drawn  attention  to  this  subject  regards  them  as 
suggestive  of  early  cancer,  and  with  him  various  other  authors  agree. 
The  infusoria  are,  however,  often  present  in  the  tartar  of  carious  teeth 
and  may  readily  be  swallowed.  They  may  be  found  in  achylia  of  non- 
cancerous origin,  and  are  therefore  not  ])athogn()m()nic  of  maligniincy. 


PHYSICAL  SIGNS  AND  X-RAY  EXAMINATION  257 

Their  presence  in  the  stomach  implies  merely  the  combination  of  carious 
teeth  and  a  lack  of  acid  secretion  in  the  fasting  stomach. 

Pus  cells  commonly  occur  in  the  gastric  contents  of  advanced  cases. 
They  may  arise  either  from  the  ulceration  of  the  growth  or  from  a 
localized  phlegmon  of  the  adjacent  portions  of  the  wall  of  the  stomach. 
To  be  of  any  diagnostic  significance  purulent  inflammation  of  other 
parts,  such  as  the  mouth,  gums,  tonsils,  throat  and  bronchi,  must  be 
excluded.  Pus  that  is  discernible  by  the  naked  eye  usually  indicates 
adhesions  to  and  perforation  into  an  adjacent  solid  viscus  forming  an 
abscess  cavity  communicating  with  the  stomach. 

Fragments  of  cancer  tissue  ma}^  be  found  in  the  fasting  contents, 
but  they  are  rarely  of  use  for  early  diagnosis.  In  many  instances  the 
fragments  are  necrotic  and  are  unfit  for  histological  examination. 

Examination  of  the  Test  Breakfast. — It  is  a  general  rule  that  if 
evidences  of  stagnation  are  found  in  the  fasting  state  they  will  also 
be  present  in  the  test  breakfast.  If  the  fasting  stomach,  however,  be 
emptied  of  its  contents  just  before  the  giving  of  the  test  breakfast, 
or  if  the  patient  has  recently  vomited,  the  test  breakfast  will  be  nearer 
the  normal  than  if  the  stomach  had  not  thus  been  emptied  before  the 
test  breakfast  was  taken.  At  first  sight  it  may  even  be  that  the  test 
breakfast  shows  very  little  evidence  of  impaired  motility,  but  on  more 
careful  examinations  there  is  almost  always  found  conclusive  evidence 
of  stasis  in  the  test  breakfast  if  stagnation  has  been  also  evident  in  the 
fasting  state.  •  Such  apparent  discrepancies  between  the  fasting  exami- 
nation and  the  test  breakfast  is  not  at  all  uncommon.  The  following 
case  is  illustrative: 

N.  B.,  aged  fifty-nine  years,  was  well  and  of  good  digestion  until 
ten  months  ago,  when  he  began  to  lose  flesh  and  strength,  and  food 
became  repulsive  to  him.  Seven  months  ago  a  pain  began  in  the  region 
of  the  stomach,  of  a  dull  aching  character,  usually  occurring  about 
an  hour  after  eating  and  only  partially  relieved  by  vomiting.  For 
three  months  he  has  vomited  nearly  every  evening  a  large  quantity 
of  offensive  material. 

Physical  Examination.  — A  mass  of  the  size  of  a  mandarin  is  dis- 
tinctly palpable  in  the  epigastrium,  hard,  irregular,  and  slightly 
tender,  descending  with  respiration  and  capable  of  expiratory  fixation. 
Patient  shows  marked  cachexia.  Red  cells,  2,600,000;  hemoglobin,  21 
per  cent. 

Examination  of  fasting  stomach  shows  520  c.c.  of  brownish  offensive 
contents  separating  on  standing  into  two  layers,  the  upper  three-fifths 
being  of  liquid,  the  lower  two-fifths  being  composed  of  food  remains. 
Total  acidity  70,  free  hydrochloric  acid  56.  Blood  positive.  No  lactic 
acid,  sarcinse  or  Oppler-Boas  bacilli  present. 
17 


258  CANCER  OF  THE  STOMACH 

Test  breakfast  given  immediately  after  the  removal  of  the  fasting 
contents  shows  90  c.c.  of  well-digested  food  remains  of  normal  acidity. 
Although  to  the  eye  the  test  breakfast  appeared  perfectly  normal, 
microscopical  examination  showed  the  presence  of  many  meat  fibers 
and  other  food  remains  sufficient  to  afford  conclusive  proof  of  stag- 
nation. 

Normal  Test  Breakfast. — The  test  breakfast  in  gastric  cancer  was 
normal  in  15  per  cent,  of  the  writer's  cases. 

While  it  is  a  general  rule  that  normal  fasting  conditions  and  normal 
test  breakfasts  go  together  in  the  same  patient,  it  may  happen  that 
one  or  the  other  may  show  a  deviation  from  the  normal  sufficient 
to  afford  some  clue  to  the  diagnosis,  hence,  the  writer's  insistence 
upon  the  double  examination,  the  importance  of  which  is  shown  in  the 
following  instances: 

Fasting  stomach  normal.     Test  breakfast  indicative  of  cancer. 

J.  C,  aged  fifty-seven  years,  was  practically  well  until  seven  weeks 
ago,  when  he  began  to  complain  of  weakness,  loss  of  appetite,  and  short- 
ness of  breath.  He  became  so  weak  that  he  was  obliged  to  stay  in  bed 
nearly  all  the  time.     He  has  had  no  dyspeptic  symptoms  whatever. 

Physical  Examinaiion. — A  firm,  slightly  tender  mass  is  palpable  in 
the  epigastrium  just  to  the  left  of  the  median  line,  descending  with 
respiration.     Signs  of  fluid  are  present  at  both  bases  behind. 

Examination  of  the  fasting  stomach  shows  the  organ  to  be  absolutely 
empty. 

Test  breakfast:  15  c.c.  well  digested  breadstuff's  without  free  or  com- 
bined hydrochloric  acid.  Lactic  acid  and  Oppler-Boas  bacilli  present. 
Blood  positive.  Autopsy  showed  carcinoma  of  the  lower  curvature 
with  metastases  in  the  liver,  both  lungs  and  pleurse  and  pericardium. 

Case  with  stasis  in  the  fasting  stomach.    Test  breakfast  normal. 

B.  B.,  aged  thirty-eight  years,  no  previous  gastric  history.  Seven 
months  ago  she  began  to  raise  gas  of  an  ofi'ensive  odor  and  to  suffer 
from  occasional  attacks  of  diarrhea.  She  has  not  lost  flesh  nor  strength 
but  comes  for  advice  because  she  has  herself  been  able  to  feel  a  lump 
in  her  stomach. 

Physical  Examination. — A  freely  movable  mass  of  the  size  of  a  lemon 
is  palpable  in  the  pyloric  region. 

Examination  of  the  fasting  stomach:  120  c.c.  of  well-digested  food 
remains  separating  on  standing  into  two  layers  of  equal  depth.  Total 
acidity  50,  free  hydrochloric  acid  28.  Lactic  acid,  Oppler-Boas  bacilli, 
and  minute  traces  of  blood  are  present. 

Test  hreakfaM:  200  c.c.  well-digested  breadstuffs  of  normal  appear- 
ance. Total  acidity  04,  free  liN-drochloric  acid  oO,  no  trace  of  lactic 
acid,  no  ()|)pler-Boas  bacilli  or  blood. 


PHYSIC  A  I,  SIGNS  AND  X-RAY  EXAMINATION  259 

Abnormality  of  Test  Breakfast. — An  abnormality  in  test  breakfast 
occurred  in  Hi)  per  cent,  of  the  patients  examined.  It  must  be  borne  in 
mind,  however,  that  many  of  these  patients  were  first  seen  in  the  ad- 
vanced stages  of  the  disease,  long  past  the  operative  period.  In  those 
who  are  seen  earlier  in  the  course  of  their  malady  the  proportion  of 
abnormal  test  breakfast  is  naturally  much  less.  It  is  more  than  probable 
that  the  majority  of  early  cancers  in  their  operative  stage  give  gastric 
analysis  which  deviate  so  slightly  from  the  normal  that  it  is  not  pos- 
sible to  make  any  diagnostic  deductions  from  them  whatever.  This  is 
unfortunate,  because  if  we  wait  for  positive  evidence  of  malignancy 
we  wait  too  long. 

Abnormalities  in  the  test  breakfast  are  of  three  varieties: 

(a)  In  52  per  cent,  of  the  cases  lactic  acid  was  present  while  hydro- 
chloric acid  was  absent  both  in  the  free  and  combined  forms. 

The  quantity  of  test  breakfast  expressed  varies  from  a  few  c.c.  up 
to  the  larger  quantities  indicative  of  pyloric  stenosis.  The  total  acidity 
ranges  from  20  to  110  or  even  higher,  but  is  almost  regularly  less  than 
in  the  contents  obtained  in  the  fasting  state.  The  odor  may  or  may  not 
be  offensive.  Sarcinse  may  very  occasionally  be  found,  their  presence 
suggesting  the  existence  of  a  previous  ulcer.  Oppler-Boas  bacilli  are 
almost  regularl}'  present  and  are  especially  abundant  in  the  minute 
brown  coagula  that  are  found  in  the  test  breakfast  in  many  instances. 

Blood  reaction  is  almost  regularly  positive.  iVlthough  this  form  of 
test  breakfast  has  been  considered  almost  pathognomonic  of  cancer  it 
may  occur  in  instances  in  which  no  neoplasm  or  other  organic  disease 
can  be  detected  by  exploration.  Such  cases,  while  uncommon,  do  occur, 
and  while  in  some  cases  no  adequate  cause  for  such  an  analysis  can  be 
adduced,  in  other  instances  definite  lesions  other  than  cancer  appear. 
Syphilitic  pyloric  lesions  and  occasionally  the  sclerosing  form  of  linitis 
plastica  may  be  accompanied  by  the  same  chemical  type  of  test 
breakfast. 

-  (h)  In  21  per  cent,  of  the  writer's  cases  neither  hydrochloric  acid  nor 
lactic  acid  was  present.  The  appearance  of  this  form  of  test  breakfast 
varies  considerably.  In  some  instances  the  appearance  is  apparently 
normal,  the  breadstuffs  being  well  digested,  of  normal  consistency  and 
quantity,  and  though  chemical  examinations  show  merely  an  absence  of 
hydrochloric  acid.  In  other  cases  the  test  breakfast  is  poorly  digested, 
contains  gastric  mucus  in  fairly  large  quantities,  resembling  exactly 
in  appearance  the  test  breakfast  obtained  in  cases  of  an  acid  catarrhal 
gastritis.  In  only  one  instance  in  the  writer's  cases  was  there  present 
the  dryish,  squeezed-out  appearance  so  characteristic  of  dry  achylia. 

Although  these  findings  are  not  at  all  characteristic  of  cancer,  as 
they  occur  frequently  enough   in   non-malignant   achylia  and  in  sub- 


260  CANCER  OF  THE  STOMACH 

acid  gastritis,  they  are  suspicious  if  they  occur  iu  a  patient  of  adult 
years  who  has  been  losing  flesh  and  strength  without  assignable  cause. 
Repeated  examinations  should  be  made  in  the  hope  of  finding  more 
definite  indications  of  malignancy  at  some  subsequent  examination. 
It  is  interesting  to  note  that  of  the  patients  of  this  type  who  came 
under  the  author's  observation,  a  clinical  history  strongly  suggestive 
of  malignant  disease  was  found  in  every  instance,  and,  moreover,  that 
in  82  per  cent,  of  these  patients  a  palpable  growth  was  found  in  the 
epigastrium,  so  that  a  diagnosis  could  be  made  without  the  help  afforded 
by  gastric  analysis.  In  many  instances  corroborative  signs  were  found 
in  the  examination  of  the  fasting  stomach.  It  should  be  remembered, 
however,  that  in  the  author's  series  of  cases  are  naturally  included  only 
those  in  which  the  diagnosis  of  cancer  had  been  positively  made. 

(c)  Both  hydrochloric  acid  and  lactic  acid  were  present  in  the  test 
breakfast  of  12  per  cent,  of  the  cases  examined.  In  all  these  instances 
])yloric  obstruction  was  present,  and  a  previous  gastric  history  suggested 
an  ulcer  was  present  in  one-half  of  these.  The  total  acidity  -s'aries 
usually  })etween  50  and  80,  free  hydrochloric  is  present  from  20  to  GO. 
Lactic  acid  reactions  are  regularly  strongly  positive  in  the  majority 
of  these  cases.  Hypersecretion  giving  reaction  for, free  hydrochloric 
acid  was  present  in  the  fasting  state  as  well,  and  the  patients  frequently 
vomit  large  quantities  of  brown  acid  fluid. 

To  tabulate  the  number  of  cases  in  which  hydrochloric  acid  and  lactic 
acid  were  present,  the  following  figures  are  reduced : 

Hydrochloric  acid  was  present  alone 1.5  per  cent. 

Hydrochloric  acid  was  present  with  lactic  acid  ...      12  per  cent. 

Total  number  with  free  hydrochloric  acid        ...      27  per  cent. 

Lactic  acid  was  present  alone 52  per  cent. 

Lactic  acid  was  present  with  hydrochloric  acid  .      .      .12  per  cent. 

Total  number  of  cases  with  lactic  acid  present     .      .     64  per  cent. 

These  figures  are  quite  different  from  those  given  by  Graham  and 
Guthrie  in  the  Mayo  clinic,  for  these  writers  found  hydrochloric  acid 
present  in  40.7  per  cent.  (70  out  of  150  cases),  while  lactic  acid  was 
present  in  42.7  per  cent.  (64  out  of  150  cases).  This  is  to  be  explained 
by  the  fact  that  in  the  Mayo  clinic  there  is  a  larger  number  of  early 
cases  positively  determined  by  exploration,  whereas,  medical  statistics 
embrace  more  cases  in  advanced  .stages  of  malignancy,  in  whom  the 
cliangcs  in  the  test   breakfast  iiuhcative  of  carcinoma  arc  marked. 

Specific  Tests  Proposed  for  the  Diagnosis  of  Gastric  Cancer. — 
The  prognosis  in   gastric  cancer  (lc|)(Mids   so   directly    iipoii   ;iii   early 


PHYSICAL  HK^NS  AND  X-RAY  EXAMINATION  2()1 

(liafj;ii()si.s  tliat  the  ([iK'stioii  of  dcNclopiiii,^  a  rcliahic  test  wliicli  shall 
(lift'eretitiate  tlic  carlv  cases  of  this  disease  from  those  coiiditioiis  which 
closely  reseinhle  it  clinically,  remains  today  one  of  the  fi;reat  unsol\-ed 
problems  in  the  field  of  medical  research.  Many  tests  have  been  pro- 
posed for  this  purpose. 

Serological  Tests. — These  may  be  classified  according  as  they  depend 
upon  {])  complement  de\'iati()n,  (2)  meiostagmin,  and  (o)  isohemolysis 
reactions. 

Complement  Deviation  Reactions. —  Normal  Serum  Hemolysis. — 
That  change  which  occurs  in  red  blood  corpuscles  when  their  hemo- 
globin is  set  free  and  passes  into  solution  is  called  hemolysis. 

It  may  be  produced  by  contact  with  many  substances,  among  which 
is  blood  serum.  The  power  of  blood  serum  to  produce  hemolysis  is 
dependent  upon  the  coordinate  action  of  two  distinct  elements  con- 
tained therein,  which  are  known  as  amboceptor  and  complement. 

Amboceptor  is  absorbed  by  the  red  cells  and  renders  them  susceptible 
to  the  dissolving  action  of  complement.  Thus  amboceptor  is  the 
sensitizing,  and  complement  the  dissolving  agent.  Amboceptor  alone 
has  no  power  to  hemolyze  red  cells.  Complement  has  the  power  of 
hemolysis  of  red  cells  only  when  they  have  been  sensitized  by 
amboceptor. 

Amboceptors  active  against  the  red  cells  of  certain  species  exist 
naturally  in  normal  sera.  Also  by  repeated  injection  into  an  animal 
of  sheep's  red  cells,  there  is  developed  in  the  serum  of  that  animal  an 
amboceptor  active  against  sheep's  cells.  Thus  there  are  two  kinds  of 
amboceptors  which  are  known  as  normal  and  immune  amboceptors 
respectively.  Immune  amboceptors  are  the  more  dependable  and 
therefore  are  the  more  used.  Amboceptor  for  use  against  sheep's  red 
cells  is  often  obtained  from  the  serum  of  rabbits  which  have  been 
repeatedly  injected  with  sheep's  red  cells. 

Amboceptor  and  complement  in  a  serum  may  be  separated  from  each 
other  because  of  different  physical  characteristics.  Amboceptor  is  the 
more  stable,  retains  its  activity  for  a  long  time,  and  is  not  injured  by 
exposure  to  a  temperature  of  55°  C.  Complement  deteriorates  rapidly, 
and  is  destroyed  by  exposure  to  this  temperature  for  thirty  minutes. 
For  practical  purposes  complement  is  obtained  usually  from  the  serum 
of  freshly  drawn  guinea-pig's  blood. 

If,  under  certain  conditions,  to  a  suspension  containing  a  certain 
amount  of  washed  sheep's  red  cells  there  be  added  proper  amounts  of 
amboceptor  (obtained  as  described  above)  and  complement  (fresh 
serum  from  a  guinea-pig)  the  red  cells  will  be  hemolyzed.  This  phenom- 
enon is  known  as  normal  serum  hemolysis.  If  either  amboceptor  or 
complement  are  missing  hemolysis  will  not  take  place. 


262  CANCER  OF  THE  STOMACH 

Aniigens  and  Antibodies. — Various  su})staiK'es  when  injected  into 
animals  cause  the  formation  of  corresponding  specific  reaction  products 
in  those  animals.  Substances  which  have  this  power  are  called  antigens 
and  the  reaction  products  are  called  antibodies.  Bacteria  and  certain 
forms  of  foreign  protein  when  injected  into  animals  are  antigens  because 
they  gi\'e  rise  to  corresponding  antibodies.  The  infectious  agent  in 
syphilis  may  be  considered  an  antigen,  for  when  it  is  introduced  into 
the  body  it  gives  rise  to  specific  syphilitic  antibodies.  Its  cultivation 
to  any  extent  has  thus  far  been  impracticable,  but  it  has  been  found  that 
extracts  of  certain  syphilitic  tissues,  such  as  an  aqueous  extract  of 
syphilitic  fetal  liver,  act  as  antigen  toward  syphilitic  antobodies. 

Complement  Deviation. — The  relationship  between  antigen  and  anti- 
body presents  two  striking  characteristics:  (1)  A  given  antibody  reacts, 
outside  of  the  body,  with  the  antigen  from  which  it  resulted  and  with 
no  other.  (2)  A  combination  of  antigen  and  its  specific  antibody, 
when  added  in  proper  proportions  to  the  elements  necessary  for  normal 
serum  hemolysis,  has  the  power  of  absorbing  complement,  thus  prevent- 
ing the  hemolysis.  The  combination  of  antigen  and  any  other  than 
its  specific  antibody  will  not  result  in  the  absorption  of  complement. 
This  phenomenon  is  known  as  complement  deviation  or  compJenient 
fixation,  and  it  is  the  basis  of  the  Wassermann  test  audits  modifications 
for  the  diagnosis  of  syphilis. 

Application  of  Complement  Deviation  to  Diagnosis. — The  five  elements 
in  the  Wassermann  reaction  and  the  concrete  substances  by  which  each 
may  be  represented  are: 

1.  Syphilitic  antigen^aqueous  extract  of  syphilitic  fetal  liver. 

2.  Syphilitic  antibody — that  contained  in  the  blood  serum  of  a 
syphilitic  patient. 

3.  Red  blood  corpuscles — those  from  sheep's  blood,  washed  and  put 
in  a  suspension  of  definite  strength. 

4.  Amboceptor — obtained  from  the  serum  of  a  rabbit  which  has 
been  repeatedly  injected  with  sheep's  red  corpuscles. 

5.  Complement — fresh  guinea-pig's  blood  serum. 

The  accurate  combination  of  these  five  elements,  under  suitable 
conditions,  will  not  result  in  hemolysis,  because  the  combination 
of  specific  antibody  and  its  antigen  has  absorbed  complement  and 
therefore  it  cannot  exert  its  hemolyzing  action  on  the  red  corpuscles 
sensitized  by  amboceptor.  Such  a  result  is  a  positive  reaction,  for  the 
serum  from  the  patient  must  have  contained  syphilitic  antibodies. 

If,  however,  blood  serum  from  a  non-sy])hilitic  individual  be  used 
instead  of  that  from  a  syijjiilitic  i)aticnt,  there  will  be  no  syphilitic 
antibodies  present  to  combine  with  antigen — for  the  absorption  of 
complement,  and  coinpleinent  will  remain  free  to  ])roduce  hemolysis. 


I' II  Y  sir  A  L  SKINS  AND   X-IiAY   EXAMINATION  263 

This  is  a  iie<i;ati\'t'  reaction;  the  serum  used  could  not  hax'c  contained 
s\j)iiiHtic  antibodies. 

Thus,  in  this  case,  with  a  known  antigen,  the  presence  or  absence 
of  its  specific  antibodies  in  an  unknown  serum  may  be  demon- 
strated. 

An  attempt  has  been  made  to  apply  the  principle  (jf  complement 
deviation,  which  has  been  of  such  remarkable  value  in  the  diagnosis 
of  syphilis,  to  the  diagnosis  of  early  cancer.  Many  elaborate  researches 
have  been  undertaken  in  the  hope  of  finding  an  antigen — perhaps  an 
extract  of  cancerous  tissue — which  would  combine  with  the  anti- 
bodies supposed  to  exist  in  the  serum  of  patients  suffering  from  cancer, 
to  absorb  complement.  Aqueous  and  alcoholic  extracts  of  cancerous 
tumors  have  been  most  tried  as  antigens.  Among  the  investigators 
in  this  field  are:  Sampietro  and  Tesa,^  Simon  and  Thomas,- Ravenna,^ 
Sisto  and  Jona,^  Weinburg  and  Mello,^  De  Marchis,'^  Guillot  and  Dau- 
fesne,^  Hirschfeld,^  and  von  Dungern.^  The  results  obtained  by  them 
are  not  altogether  uniform.  Some  obtained  positive  reactions  in  cases 
that  were  not  cancerous  and  many  in  syphilis.  Some  failed  to  obtain 
reactions  of  any  kind;  others  noticed  that  in  all  cases  in  their  series 
giving  negative  reactions  were  those  of  cancer  of  the  uterus  or  alimen- 
tary tract,  von  Dungern's  results  are  more  nearly  consistent  than 
others.  However,  it  must  be  concluded  that  the  actions  of  the 
antigens  thus  far  used  have  not  been  specific  enough  to  certainly 
differentiate  cancer  from  syphilis,  benign  newgrowths,  and  other 
conditions. 

Meiostagmin  Reactions  {n-zoy^ — smaller,  and  frzayiia — a  drop). 
Traube  observed  that  the  addition  of  a  toxin  to  an  antitoxin  produced 
a  lowering  of  the  surface  tension  of  the  fluids,  which  is  measured  by 
measuring  the  size  of  the  drops  with  a  stalagmometer.  Ascoli  found 
that  this  phenomenon  occurred  when  serum  from  patients  suffering 
from  certain  diseases  was  mixed,  after  suitable  dilutions,  with  an 
appropriate  antigen.  Ascoli  and  Izar^°  liave  attempted  to  prepare 
an  antigen  which  would  give  the  characteristic  reaction  with  serum 

'  Sampietro  and  Tesa.    Annal.  d'Igiene  Sperim.,  1908,  p.  657. 

^  Simon  and  Thomas.    Jour  of  Exp.  Med.,  x,  673. 

^  Ravenna.    Arch.  Scien.  Med.,  1909,  No.  6. 

^  Sisto  and  Jona.    Clin.  Med.  Ital.,  1909,  xlviii,  289. 

"Weinburg  and  Mello.     Bull.  Assoc.  Frang.  pour  I'etude  du  cancer,  1910. 

*■' De  Marchis.     Lo  Sperimentale,  1910,  p.  969. 

'  Guillot  and  Daufesne.    Bull.  Assoc.  Fran?,  pour  I'etude  du  cancer,  1910,  p.  34. 

^Hirschfeld.    Deutsch.  med.  Woch.,  1911,  No.  27. 

"von  Dungern.    Miinch.  med.  Woch.,  January  9,  1912. 

'"AscoU  and  Izar.    Miinch.  med.  Woch.,  Nos.  8,  IS,  and  22 


264  CANCER  OF  THE  STOMACH 

from  cancer  patients.  Although  some,  with  tliis  method,  have  olitained 
a  positi\'e  reaction  in  a  small  percentage  of  other  pathological  conditions, 
the  results  have  thus  far  been  very  encouraging.  Krauss,  von  Graff, 
and  Ranzi^  consider  it  the  most  reliable  of  the  serum  reactions. 

IsoHEMOLYSis  REACTIONS. — The  tests  in  this  group  depend  upon 
that  property  of  the  serum  of  patients  suffering  from  certain  diseases 
which  produces  hemolysis  of  normal  red  blood  corpuscles  from  the 
same  species.  Weil-  showed  that  the  serum  of  dogs  suffering  from 
lymphosarcoma  hemolyzed  the  red  blood  corpuscles  of  normal  but 
not  of  sarcomatous  dogs.  He  and  other  observers  have  studied  the 
same  phenomenon  in  human  cancer  patients. 

Judging  from  the  results  up  to  the  present  time  from  all  observers, 
it  is  probable  that  the  reaction  occurs  in  less  than  half  of  all  cases  of 
cancer.  ]Moreover,  it  has  been  found  to  take  place  in  a  few  normal 
individuals  and  in  a  considerable  number  suffering  from  other  patho- 
logical conditions. 

Elsberg^  by  injecting  under  the  skin  of  cancerous  patients  a  small 
amount  of  a  20  per  cent,  suspension  of  washed  defibrinated  blood,  and 
observing  the  subsequent  local  reaction,  has  obtained  results  that  seem 
remarkably  constant.  This  test  has  been  favorably  reported  upon  by 
Leitch. 

Tryptophan  Tests  depend  upon  the  detection  in  the  gastric  contents 
of  a  product  of  the  action  of  the  proteolytic  ferment  which  malig- 
nant neoplasms  have  been  reported  to  contain.  It  is  maintained  that 
the  normal  gastric  ferments  have  no  power  to  carry  the  digestion  of 
proteids  farther  than  the  peptone  stage.  In  1909  Xeubauer  and  P'ischer* 
announced  that  the  cancer  ferment  had  the  power  of  hydrolyzing 
simple  peptids.  One  of  the  products  of  this  cleavage  when  the  dipeptid 
glycyl-tryptophan  is  acted  uj^on  is  tryptophan,  an  amino-acid  whose 
presence  in  gastric  contents  is  readily  detected.  The  "glycyl- 
tryptophan  test"  of  Xeubauer  and  Fischer  depends  upon  this 
reaction. 

Weinstein^  maintains  that  the  addition  of  glycyl-tryptophan  to  the 
stomach  contents  is  unnecessary  because  the  cancer  ferment  will  con- 
vert the  peptones  of  the  test  meal  itself  into  amino-acids,  among  which 
is  tryptophan.  Accordingly  he  uses  a  niodification  of  the  glycyl-tryp- 
tophan test  in  which  the  filtrate  from  the  test  meal  is  tested  directly 

'  Krauss,  v.  Graff,  and  Ranzi.    Wien.  klin.  Wocli.,  1911,  No.  28. 

2  Weil.    Jour.  Amer.  Med.  Assoc,  1908,  p.  158. 

'  Elsberg.    Jour.  Amer.  Med.  Assoc,  March  27,  1909. 

■•  Xeubauer  and  Fischer.     Deutsrh.  Archiv.  f.  klin.  Med.,  1909,  xciii,  499. 

'■  Weinstein.    Jour.  Amer.  Med.  Assoc,  1910,  Iv,  1085. 


PHYSICAL  SIGNS  AM)  X-RAY  EX  A  MIX  AT  ION  265 

for  the  presence  of  try])toi)Ii;m  without  the  prexious  addition  of  glycyl- 
tryptophan.     This  is  known  as  the  tryptopiian  test.' 

These  tests  have  been  stuched  by  Friechnan,-  Hall  and  Williamson,^ 
Kohlenberger,^  Lyle  and  Kober/  Oppenheim,*'  Sanford  and  Rosen- 
bloom/  Smithies,^  Warfield,^  Weinsteinji*^  and  others.  A  consider- 
able difference  of  opinion  prevails  among  them  in  regard  to  the  factors 
which  may  l)e  considered  to  invalidate  the  tests.  The  presence  of 
blood,  bile,  regurgitated  duodenal  contents,  swallow^ed  saliva,  bac- 
teria, or  of  low  or  high  acidity,  or  anacidity,  are  regarded  variously 
as  rendering  them  worthless  or  having  no  effect  whatever  on  the  result. 
No  more  uniform  are  the  conclusions  regarding  the  practical  value 
of  the  tests.  As  is  so  often  the  case  wdien  new  methods  are  on  trial, 
the  earlier  reports  are  the  more  enthusiastic. 

Smithies^^  has  presented  a  valuable  report  of  a  most  extensive  series 
of  cases  of  gastric  disorders  in  w^hich  a  routine  application  of  modifica- 
tions of  both  tests  w-as  made  in  each  case.  In  his  series,  of  all  of  the 
proved  cases  of  cancer  of  the  stomach  more  than  one-third  gave  positive 
glycyl-tryptophan,  and  one-thirteenth,  positive  tryptophan  reactions, 
but  in  each  of  these  cases  the  diagnosis  was  quite  possible  independent 
of  these  methods.  While  in  many  cases  of  gastric  conditions  other  than 
cancer  a  positive  glycyl-tryptophan  reaction  was  obtained,  still  in  no 
single  class  of  diseases  of  the  stomach  was  the  test  obtained  so  frequently 
as  in  cancer.  He  concludes  also  that  in  cases  of  cancer  of  the  stomach 
the  glycyl-tryptophan  reaction  appeared  more  consistently  than  did  the 
tryptophan  reaction.  While  it  cannot  be  stated  that  these  tests  will 
never  prove  to  be  of  any  value,  still  the  statistics  thus  far  reported 
make  it  clear  that  at  the  present  time  they  are  unreliable  and  of  no 
assistance  in  the  early  diagnosis  of  gastric  cancer. 

Salomon's  Test. — Salomon's^^  test  depends  upon  the  recovery  from  the 
stomach  washings  of  a  larger  amount  of  albumin  and  nitrogen  than  is 

^  For  details  of  the  technique  of  the  glycyl-tryptophan  and  tryptophan  tests  see 
Lyle  and  Kober,  New  York  Med.  Jour.,  June  4,  1910,  xci,  1152,  and  Weinstein, 
Jour.  Amer.  Med. 'Assoc,  October  28,  1911,  Ivii,  1424. 

-Friedman.    Archives  of  Diagnosis,  1911,  iv. 

^  Hall  and  Williamson.    Lancet,  March  18,  1911,  731. 

■"  Kohlenberger.     Deutsch.  Archiv  f.  kUn.  Med.,  1910,  xcix,  148. 

^  Lyle  and  Kober.     New  York  Med.  Jour.,  June  4,  1910,  xci,  1152. 

"Oppenheim.     Deutsch.  Archiv.  f.  kUn.  Med.,  1910-11,  ci,  293. 

'  Sanford  and  Rosenbloom.    Archives  of  Int.  Med.,  April  ,1912,  ix,  450. 

-  Smithies.    Archives  of  Int.  Med.,  October  15,  1912,  x,  357. 

3  Warfield.    Bull.  Johns  Hopkins  Hosp.,  May,  1911,  150. 

'"Weinstein.    Jour.  Amer.  Med.  Assoc,  October  28,  1911,  hii,  1424. 

''Smithies.     Archives  of  Int.  Med.,  October  15,  1912,  x,  450. 

'-Salomon.    Deutsch.  med.  Woch.,  1903,  No.  31. 


200  CAXCPJR  OF   THE  STOMACH 

normally  present.  The  tissue  destruction  in  jrastric  cancer  is  supposed 
to  be  accompanied  by  the  pouring  out  of  an  albuminous  serum.'  Since 
the  announcement  of"  this  test  in  1903  many  have  endeavored  to 
establish  its  true  value.  It  is  conceded  to  be  of  some  value  in  assisting 
in  the  diagnosis  of  extensive  ulceration,  but  of  very  little,  if  any,  in 
differentiating  benign  from  malignant  conditions,  especially  when  the 
latter  are  of  the  difl'use  infiltrating  type.  This  applies  also  to  the 
several   modifications  of  the  test  that   have  been  proposed. 

Ueissner  has  proposed  a  test  in  which  the  amount  of  chlorides  in  the 
stomach  contents  is  estimated.  He  believes  that  in  cases  of  cancer  the 
amount  of  chlorides  poured  out  into  the  stomach  is  much  increased  over 
the  normal  amount.    This  test  has  not  been  demonstrated  to  be  of  value. 

Livierato'  has  proposed  to  inject  subdurally  into  previously  sen- 
sitized animals,  thoroughly  filtered  gastric  juice  from  suspected  cases, 
being  led  to  believe  from  previous  experimentation  that  those  animals 
injected  with  gastric  juice  from  cancerous  stomachs  will  show  symptoms 
of  anaphylaxis,  while  the  others  will  not. 

This  and  the  other  almost  innumerable  tests  of  various  kinds  that 
have  been  proposed  for  the  early  diagnosis  of  gastric  cancer  are  subject 
to  too  many  important  sources  of  error  to  be  of  an\'  value. 

COMPLICATIONS 

Perforation. — An  important  group  of  complications  due  to  perfora- 
tion of  the  growth  occurs  in  a  little  over  4  per  cent,  of  the  cases.  Per- 
foration if  not  limited  by  adhesions  about  the  base  of  the  growth  may 
excite  a  general  peritonitis,  but  if  the  leakage  is  slight  or  limited  by  pre- 
existing adhesions,  the  chronic  form  of  perforation  occurs,  leading  to 
the  formation  of  localized  abscesses. 

General  Peritonitis. — If  acute  perforation  occurs  late  in  the  course  of 
the  disease  when  the  patient  is  seriously  prostrated,  it  may  be  attended 
by  symptoms  that  arc  far  less  conspicuous  than  those  which  ordinarily 
attend  perforative  ])eritonitis.  The  actual  perforation  may  be  preceded 
by  an  increased  ])ain  and  distress  more  or  less  constant  in  character 

'  .\  i)roliminary  non-albuniinou.s  fluid  diet  is  given  for  twenty-four  hours.  The 
evening  before  the  stonuicli  i.s  carefully  washed.  Next  morning  the  stomach  is 
again  washed  thoroughlj'  with  400  c.c.  of  normal  saline  solution,  the  same  fluid 
being  used  repeatedly.  The  fluid  used  is  then  tested  for  albumin  and  nitrogen  by 
Esbach's  and  Kjeldahl's  metiiods.  More  than  0.5  gm.  of  albumin  or  '20  mg.  of 
nitrogen  to  100  c.c.  of  the  fluid  is  said  to  be  suggestive  of  cancer.  In  negative  cases 
there  should  be  little  or  no  turbidity  with  Ksbach's  reagent,  and  the  nitrogen 
(Kjeldahl)  is  not  greater  than  1.5  mg. 

-  Livierato.  Die  Magen.saft;  .Anaphylaxie;  Ainv('n(huig  dieselben  zur  Diagnose 
des  Magciikrebses. 


COMI'IJCATIOXS  2(57 

and  associated  with  tt'iidcriiess  and  possibly  witli  rif^idity  of  the  upper 
abdominal  wall.  In  other  instances  hematemesis  from  the  sloughing 
of  the  mass  may  precede  the  accident.  It  is  usual  at  the  time  of  the 
perforation  for  the  patient  to  experience  sharp  agonizing  pain  in  the 
epigastrium  which  rapidly  becomes  diffused  over  the  entire  abdomen, 
but  in  cases  in  which  the  peritoneum  has  been  previously  implicated 
bj'  malignancy,  as  well  as  in  those  patients  who  are  greatly  exhausted 
by  the  disease,  the  pain  may  be  slight  or  even  absent,  or  may  not  differ 
in  the  least  from  pains  previously  experienced.  In  these  advanced 
patients,  however,  there  is  a  marked  change  in  their  appearance.  They 
look  sick;  the  nose  is  pinched,  the  eyes  receded  into  their  sockets,  the 
surface  of  the  body  is  cold,  slightly  cyanotic,  and  may  be  covered 
by  beads  of  cold  perspiration.  The  facies  is  often  typical  of  acute 
septic  peritonitis.  In  almost  all  cases  there  is  general  distention  of 
the  abdomen,  with  tenderness  and  rigidity,  although  these  signs  are 
not  invariably  present.  It  is  rare  for  the  patient  to  live  more  than 
three  days  after  the  accident. 

Localized  Perigastric  Abscess. — Localized  perigastric  abscess  occurs 
more  frequently  than  does  complete  and  sudden  perforative  peritonitis. 
The  pathological  anatomy  of  such  an  accident  is  practically  that  of 
incomplete  localized  perforation  of  ulcer,  and  need  not  therefore  be 
given   in   detail   in   this   connection. 

Abscesses  of  the  anterior  abdominal  wall  communicating  with  the 
stomach  are  of  infrequent  occurrence,  only  about  25  instances  of  cuta- 
neous gastric  fistulse  being  recorded. 

Subphrenic  abscess  is  not  uncommon.  The  lesser  peritoneal  sac 
may  be  full  of  foul-smelling  pus,  and  may  contain  air.  Secondary 
infections  above  the  diaphragm  may  occur,  fibrous-serous  pleurisy, 
empyema,  or  even  abscess  or  gangrene  of  the  lung,  even  though  there 
be  no  metastases  in  the  thoracic  viscera.  Pneumothorax  or  pneumo- 
pericardium may  follow  perforation  of  the  esophagus  by  cancerous 
ulceration  that  has  invaded  this  structure  from  the  cardia. 

Symptoms. — The  symptoms  of  localized  perigastric  abscess  depend 
upon  the  stage  of  the  original  gastric  complaint  in  which  the  complica- 
tion occurs  and  upon  the  intensity  of  the  local  inflammatory  process. 
An  increase  in  the  pain  is  usually  noted,  not  only  in  intensity,  but  in  its 
constancy.  Constant  epigastric  or  abdominal  pain  in  cancer,  especially 
if  accompanied  by  leukocytosis  or  a  relative  polynucleosis  usually  is 
suspicious  evidence  of  abscess  or  sinus  formation.  Circumscribed 
abscesses  that  are  in  contact  with  the  anterior  abdominal  wall  usually 
give  rise  to  a  visible  or  a  tangible  tumor  which  shows  fixation  and 
undergoes  no  respiratory  excursions.  The  abdominal  wall  over  such  an 
area  is  usually  exquisitely  tender  and  quite  rigid. 


268  CANCER  OF  THE  STOMACH 

Suhphreiiic  abscesses  may  give  tise  to  considerable  (lys})nea,  nausea, 
vomiting,  with  repeated  retching  and  fairly  constant  i)ain.  Physical 
examination  usually  shows  considerable  bulging  of  the  hypochondria, 
and  a  limitation  of  the  respiratory  movements  of  the  lower  thorax  of  the 
affected  side.  A  characteristic  tympany  or  even  an  amphoric  note  may 
be  elicited  by  percussion;  metallic  tinkle  may  be  distinctly  audible. 
The  apex  of  the  heart  in  left-sided  subdiaphragmatic  abscesses  may 
be  displaced  upward  and  to  the  left. 

Fever  is  usually  persistent  in  all  forms  of  extragastric  suppuration 
and  assumes  a  septic  type.  Leukocytosis  or  polynucleosis  is  frequent. 
In  a  case  of  the  writer's  of  subphrenic  pyropneumothorax  the  leuko- 
cytes were  7000,  but  on  differential  count  the  polynuclears  were  93 
per  cent. 

In  suspected  cases  the  vomited  matters  should  be  examined  for  pus 
cells,  as  in  almost  all  instances  of  incomplete  perforation  they  are 
quite  abundant  and  afford  material  aid  in  diagnosticating  the  presence 
of  this  complication. 

Although  in  the  great  majority  of  instances  perigastric  abscesses 
may  be  sus])ected  or  even  correctly  diagnosticated,  it  not  infrequently 
happens  that  the  discovery  of  the  abscess  at  autopsy  is  quite  unexpected, 
and  on  looking  over  the  clinical  notes  of  the  case  all  the  evidence  it 
gave  of  its  presence  was  that  the  patient  looked  more  ill,  and  weaker 
and  more  prostrated,  ran  a  little  temperature,  and  passed  rapidly  into 
a  downward  course  tow'ard  dissolution. 

Fistulas  May  Form. — Cutaneous  fistula  is  quite  infrequent.  Gastro- 
colic fistulas  are  more  common  and  are  said  to  occur  in  about  2  per 
cent,  of  cases  of  cancer  of  the  stomach,  although  the  writer  thinks 
that  this  estimate  is  altogether  too  high. 

Symptoms. — The  two  important  symptoms  are: 

1.  Fecal  vomiting. 

2.  Lienteric  diarrhea. 

P^ither  or  both  of  these  symptoms  may  be  absent. 

In  4:3  cases  collected  by  Edsall  {Amer.  Med.,  October  10,  1903),  fecal 
vomiting  was  present  in  29  and  absent  in  10  cases.  The  vomiting  may 
be  ])recedcd  by  pain,  or  a  feeling  as  if  something  had  given  way  and 
usuall\'  comes  on  suddenly  and  not  gradually,  as  in  peritonitis  or  ob- 
struction. The  vomited  matters  are  evidently  from  the  large  intestine, 
brown  and  distinctly  fecal,  and  exhibit  the  same  characteristics  as  the 
bowel  evacuations. 

It  is  imi)ortant  to  distinguish  })etween  the  true  fecal  odor  and  a  foul 
odor  due  to  ulceration  and  sloughing  of  the  cancer  mass.  Feculent 
vomiting  is  not,  however,  characteristic  of  gastrocolic  fistula  even  in 
the  a})sence  of  intestinal  occlusion  or  paralysis,  as  it  may  occur  in 


COMPLICATIONS  269 

hysteria,  and  even  in  the  course  of  cancer  of  the  stomach,  fecal  vomiting 
may  occur  without  either  intestinal  obstruction  or  gastrocolic  fistula. 
It  is  suppovSed  that  the  cause  for  the  fecal  vomiting  in  these  latter 
cases  is  a  rigid  patency  of  the  pylorus,  from  cancerous  infiltration, 
so  that  it  is  unable  to  contract  sufficiently  to  prevent  the  passage 
through  it  of  intestinal  contents  forced  l)ackward  by  a  process  of 
reversed  peristalsis. 

It  not  infrequently  happens  that  should  a  gastrocolic  fistula  form 
during  the  course  of  pyloric  cancer,  the  vomiting  characteristic  of  pyloric 
stenosis  may  cease  and  an  apparent  improvement  in  the  patient's 
condition  may  be  quite  noticeable.  "  The  patient  vomits  into  his  own 
intestine,"  but  the  improvement  is  only  temporary.  Continued  nausea 
usually  accompanies  such  a  condition. 

Fecal  vomiting  may  be  absent  if  the  fistulous  opening  is  too  small 
to  allow  the  fecal  masses  to  get  into  the  stomach.  It  may  also  happen 
that  fecal  contents  may  enter  the  stomach,  and  instead  of  being  vomited 
reenter  the  bowel  through  the  pylorus  or  through  a  gastrojejunostomy 
opening.  In  a  case  reported  b,y  Kelling  the  distended  stomach  squeezed 
the  colon  walls  together  to  form  a  valve  so  that  the  entrance  of 
the  stomach  contents  through  the  colon  was  prevented.  Severe 
diarrhea  with  evacuations  containing  large  quantities  of  totally  un- 
digested food  passed  soon  after  its  ingestion,  is  observed  if  the  false 
passage  be  of  sufficient  size.  Rapid  emaciation  naturally  ensues.  These 
characteristics  of  the  stools  are  frequently  overlooked. 

Diagnosis. — The  diagnosis  may  be  corroborated  by  the  finding  of 
colored  fluids  introduced  by  rectum,  in  the  stomach  or  in  the  vomited 
matters,  and  conversely  by  the  rapid  passage  of  colored  fluids  taken 
by  mouth  through  the  colon  and  appearing  in  the  stools,  often  within 
the  hour.  Inflation  of  the  bowel  by  air  does  not  distend  the  ascending 
portion  of  the  colon,  but  inflates  the  stomach,  and  the  air  is  eructated 
with  a  distinctly  foul  and  fecal  odor. 

A'-rays  should  show  the  lesion  clearly  and  should  definitely  establish 
the  diagnosis  without  any  loopholes  for  doubt. 

Metastases. — The  symptoms  of  the  various  metastases  are  too  well 
known  to  require  more  than  the  briefest  reference. 

Metastases  in  the  liver  usually  overshadow  in  growth  the  primary 
source  of  disease  in  the  stomach  and  give  symptoms  predominating 
those  of  gastric  origin.  In  many  instances  the  original  cancer  in  the 
stomach  becomes  quiescent  and  clinically  latent,  as  soon  as  metastases 
form  in  the  liver. 

The  advent  of  cancerous  peritonitis  is  usually  insidious.  In  half  of 
the  writer's  cases  of  this  complication  there  was  neither  pain,  rigidity, 
nor  any  fever,  and  in  the  majority  of  these  the  swelling  of  the  abdomen 


270  CANCER  OF   THE  STUMACH 

was  noticed  by  the  patient  before  there  was  complaint  of  any  discom- 
fort whatever.  In  but  one-third  of  the  cases  was  pain  a  prominent 
feature.  When  pain  is  present  it  may  be  of  a  dull  character  distributed 
over  the  entire  abdomen,  or  the  pain  may  be  sharp,  lancinating,  and 
even  colicky.     Occasionally  radiation  down  the  leg  may  be  observed. 

General  Complications. — Pneumonia  is  not  an  uncommon  complica- 
tion and  usually  constitutes  the  terminal  event.  Aspiraiion  pneumonia , 
gangrene  or  abscess  of  the  lung  may  occur,  being  especially  frequent 
with  cancer  of  the  cardia  that  has  extended  into  the  esophagus.  Poly- 
nenriiis  may  give  rise  to  severe  peripheral  pains,  usually  accompanied 
by  an  increase  in  the  reflexes,  although  the  reflexes  may  be  diminished 
or  even  absent.  Thrombosis,  usually  of  the  larger  veins  in  the  leg  or 
thigh,  is  not  uncommon  in  cachectic  patients,  and  may  even  occur 
before  the  appearance  of  gastric  symptoms. 

There  are  cases  not  uncommonly  observed  which  assume  the  type 
of  a  simple  ascites,  common  to  affections  of  the  heart,  liver  or  kidneys. 
The  patient  will  complain  of  loss  of  strength  and  occasional  vomiting, 
but  without  any  symptoms  that  point  toward  any  serious  disease  of 
the  stomach  itself.  The  abdomen  is  distended  with  fluid,  but  there 
is  neither  characteristic  pain  on  pressure  nor  any  other  abdominal  sign 
of  cancer.  In  many  of  these  cases  signs  of  pleuritic  fluid  are  present. 
Such  a  history  is  as  follows: 

F.  H.,  aged  fifty-six  years.  Patient  has  been  a  steady  drinker  of 
beer — about  two  quarts  a  day,  and  for  the  past  year  has  taken  whisky 
with  his  meals.  His  previous  history  was  good  until  three  weeks  ago, 
when  he  noticed  his  abdomen  was  getting  large.  About  two  weeks 
ago  the  swelling  of  the  abdomen  was  much  more  noticeable,  but  the 
only  complaint  was  a  slight  feeling  of  distention  as  if  his  clothes  were 
too  tight  for  him.  One  week  ago  he  became  a  little  short  of  breath 
and  lost  his  appetite.  At  no  time  has  he  had  pain,  nausea,  nor  any 
vomiting. 

Phi/siral  Examination. — A  poorly  developed  emaciated  man  with  a 
symmetrically  enlarged  abdomen  which  showed  by  examination  the 
presence  of  free  fluid.  There  were  signs  of  fluid  at  both  bases  behind, 
heart  negative,  urine  normal.  No  masses  could  be  felt  in  the  abdomen, 
nor  any  areas  of  tenderness.  His  red  blood  cells  were  4,o00,()()(), 
hemoglobin  70  i)er  cent.,  white  blood  cells  (iOOO,  (')(>  per  cent,  polynuclears. 
The  course  of  the  disease  after  admission  to  the  hospital  was  steadily 
downward,  the  chief  symptoms  being  swelling  of  the  abdomen,  edema 
of  the  ankles,  slight  dyspena,  and  occasional  vomiting  of  his  medication. 
Death  occurred  one  month  after  he  entered  the  hosjjital. 

Autopsy  showed  free  fluid  in  the  al)dominal  (•a\ity.  The  stomach 
was  adherent  to  the  lixcr,  diaphragm,  intestines,  pancreas,  and  spleen. 


DURATION,   DIAGNOSIS,    AND   TliKATMENT  271 

Its  walls  were  diffusely  thickened,  and  its  capacity  markedly  diminished, 
the  so-called  "leather-bottle"  stomach.  The  mesentery,  omentum, 
and  abdominal  peritoneum  were  studded  with  small  carcinomatous 
growths,  and  the  intestines  were  matted  together  by  adhesions.  There 
was  fluid  in  both  pleural  cavities  and  a  small  area  of  pneumonia  in  the 
upper  lobe  of  the  right  side.  There  were  small  metastases  in  the  heart 
muscle. 

Phlegmonous  gastritis  may  involve  the  wall  of  the  stomach  in  the 
neighborhood  of  an  ulcerating  mass.  The  phlegmon  usually  remains 
circumscribed,  and  but  rarely  gives  symptoms  of  its  own,  as  the  com- 
plication is  apt  to  occur  only  in  the  advanced  stages  of  cancer  when  the 
patient  is  too  weak  and  prostrated  for  this  complication  to  make  any 
decided  difference  in  the  clinical  course  of  the  disease. 


DURATION,  DIAGNOSIS,  AND    TREATMENT 

Duration. — The  duration  of  the  disease  is  about  one  and  a  half 
to  two  years,  being  somewhat  shorter  in  the  young  than  in  the  aged. 
The  actual  duration  is,  however,  difficult  to  determine,  because  in  some 
patients  the  symptoms  begin  early  and  in  others  they  do  not  appear 
until  the  disease  is  well  advanced  So  that  it  is  impossible  to  estimate 
how  long  the  cancer  has  existed  in  any  given  case  before  it  has  reached 
the  point  of  giving  symptoms.  It  may  happen  that  patients  run  a 
clinical  course  of  only  a  few  weeks,  while  others  suffer  for  many  months 
from  the  malady. 

Diagnosis. — The  important  problems  of  diagnosis  are  concerned  with 
the  detection  of  the  growth  in  its  early  stages  wdiile  there  is  a  chance 
that  the  disease  can  be  radically  removed  by  timely  operative  inter- 
vention. It  makes  very  little  difference  in  advanced  inoperable  cases 
whether  we  make  a  diagnosis  or  not.  The  difficulty  which  confronts 
us  in  the  early  cases  is  that  if  we  wait  for  characteristic  or  typical 
symptoms  to  clear  up  the  diagnosis  in  a  suspected  case,  we  have 
probably  waited  too  long  for  surgical  relief  to  be  radical  and  curative, 
while,  on  the  other  hand,  if  we  advise  exploration  before  we  have 
established  our  diagnosis,  we  are  often  subjecting  our  patients  to 
a  totally  unnecessary  operation. 

Diagnosis  of  Early  Cases. — The  early  cases  may  be  divided  into  two 
groups — those  who  give  an  ulcer  history,  and  those  in  whom  the  symp- 
toms appear  without  any  previous  complaint  of  indigestion. 

(a)  Early  iMtients  with  an  ulcer  history. 

In  many  patients  the  first  indication  of  trouble  with  the  stomach  is 
the  occurrence  of  a  group  of  symptoms  which  may  so  closely  resemble 


272  CANCER  OF  THE  STOMACH 

ulcer  that  a  differentiation  is  practically  impossible.  The  pains  may 
occur  two  or  three  hours  after  eating  and  are  relieved  by  eating,  as 
are  the  pains  of  ulcer.  Gastric  analysis  shows  no  essential  differences 
in  these  two  conditions. 

The  best  method  of  making  a  differential  diagnosis  in  these  cases 
is  to  put  the  patient  at  once  on  a  rigid  ulcer  cure.  He  should  be  put 
to  bed  with  hot  applications  over  the  abdomen,  and  a  total  abstinence 
of  food  or  drink  should  be  enforced  for  seventy-two  hours.  At  the  end 
of  this  time  peptonized  milk  is  given  in  small  quantities  according  to 
the  treatment  given  in  detail  under  the  treatment  of  ulcer.  Ordinarily 
on  this  treatment  pain  and  discomfort  cease  before  the  tenth  day,  the 
stools  become  blood-free,  and  although  there  is  an  initial  loss  from  the 
starvation  treatment  from  6  to  8  pounds,  the  patient  after  ten  days 
should  begin  to  gain  a  little.  If  in  the  case  in  point  the  patient  com- 
plains of  a  continuance  of  his  ulcer  symptoms,  if  blood  is  present  in 
the  stools  during  the  second  and  third  week  of  the  ulcer  cure,  or  should 
blood  in  the  stools  reappear  with  each  advance  in  his  diet,  if  the  patient 
should  not  regain  flesh  and  strength  in  the  third  and  fourth  week  when 
his  diet  is  sufficient  to  enable  him  to  gain,  or  if  during  the  third  and 
fourth  week  blood  examination  shows  an  increasing  chloranemia  in 
spite  of  sufficient  food,  then  the  case  should  be  regarded  as  suspicious, 
a  surgeon  of  good  judgment  and  irreproachable  technique  should  be 
called  into  the  case  and  the  question  of  exploratory  laparotomy  seriously 
discussed.  These  points  have  already  been  alluded  to  under  the  heading 
of  ulcer. 

In  other  patients  there  may  be  elicited  the  history  of  an  ulcer  in  the 
past,  the  symptoms  of  which  have  become  quiescent  so  that  it  may  be 
considered  that  the  patient  is  cured  of  the  original  disorder.  Should  such 
a  patient  complain  of  an  unexplained  or  sudden  loss  of  appetite,  or  loss 
of  weight,  together  with  vague  dyspeptic  symptoms  which  cannot  be 
explained  by  dietetic  errors,  then  the  diagnosis  of  a  carcinomatous 
degeneration  of  an  old  unhealed  ulcer  must  be  seriously  considered. 
Under  these  circumstances  it  is  wise  to  place  the  patient  on  a  gastritis 
treatment,  to  give  him  a  light  suitable  diet,  in  quantity  and  quality 
adapted  to  his  special  needs,  and  if  necessary  to  wash  the  stomach 
every  day.  Frequent  blood  counts  should  be  taken  and  the  record 
of  his  weight  duly  recorded.  If  after  a  month  of  such  treatment, 
faithfully  and  conscientiously  carried  out,  there  be  no  material  gain, 
it  is  generally  wise  to  explore,  to  determine  the  exact  conditions  that 
are  i)reventing  restoration  to  health. 

A  large  proj)ortion  of  these  patients  are  treated  by  the  physician  for 
cliroiiic  gastritis.  Especially  is  this  diagnosis  made  when  vomiting 
occurs  or  if  the  jjiitient  complain  of  discomfort  in  the  region  of  the 


DURATION,   DIAGNOSIS,   AND   TREATMENT  273 

stomach.  It  cannot  be  too  strongly  emphasized  that  vomiting  and  pain 
in  the  stomach  are  not  symptoms  of  chronic  gastritis  in  those  of  adult 
years,  and  that  a  diagnosis  of  gastric  catarrh  should  never  be  made 
on  the  presence  of  these  symptoms.  Nor  should  cancer  of  the  stomach 
be  discarded  purely  on  the  basis  of  age.  Many  cases  are  not  recognized 
simply  because  they  occur  in  young  people.  We  are  often  misled  in 
our  diagnosis  by  the  persistence  of  good  appetite  and  a  lack  of  anemic 
or  cachectic  symptoms.  It  not  infrequently  happens  that  the  patient 
retains  a  robust  appearance  and  has  a  normal  appetite  until  the  disease 
is  well  established. 

During  the  early  stages  of  cancer,  gastric  analysis  may  or  may  not  be 
of  service.  The  most  significant  sign  of  disease  is  the  presence  of  fluid 
or  of  food  remains  in  the  fasting  stomach,  indicative  of  motor  error. 
Such  stasis  may  occur  from  benign  stenosis  as  well  as  from  malignant 
disease  of  the  pylorus,  but  in  a  case  where  the  symptoms  are  obscure 
and  ill-defined,  an  increasing  food-stasis  is  highly  suspicious  of  an 
advancing  malignancy.  The  absence  of  hydrochloric  acid  means 
nothing.  Its  presence  is  common  enough  in  early  growths  and  in  in- 
stances in  which  carcinomatous  degeneration  is  implanted  on  the  base 
of  an  old  ulcer  it  may  persist  throughout  the  entire  course  of  the  disease. 
It  is  unfortunate  that  in  the  minds  of  many  an  absence  of  hydrochloric 
acid  in  the  test  breakfast  is  regarded  as  a  suspicious  sign  of  malig- 
nancy. Of  153  consecutive  cases  of  absence  of  hydrochloric  acid  in 
the  test  breakfast  in  the  writer's  private  cases,  4  were  malignant,  149 
were  non-malignant.  It  cannot  be  too  positively  affirmed,  therefore, 
that  h}'drochloric  acid  values  have  very  little  bearing  on  the  diagnosis 
of  gastric  cancer. 

(Jn  the  other  hand,  achylia  with  stagnation  justifies  exploration. 

The  presence  of  lactic  acid  is  an  extremely  suspicious  phenomenon 
though  not  pathognomonic  of  cancer  of  the  stomach  itself.  It  usually 
is  a  late  symptom,  and,  as  a  rule,  indicates  that  the  disease  is  too  firmly 
established  for  any  hope  of  radical  relief.  It  is  improbable  that  gastro- 
scopy  will  ever  be  of  any  aid  in  the  diagnosis.  The  various  chemical, 
biological,  and  hemolytic  tests  suggested  for  the  diagnosis  of  malignant 
neoplasms  may  corroborate  the  diagnosis  of  advanced  stages  of  the 
malady,  but  are  not  to  be  relied  upon  for  diagnosis  in  the  early  cases. 

Late  Cases. — In  advanced  stages  of  the  disease  there  is  usually  very 
little  difficulty  in  making  a  diagnosis,  as  we  have  the  history  of  the  case, 
the  physical  examination  and  the  gastric  analyses  to  aid  us.  No  one 
of  these  alone  is  sufficient  to  justify  a  diagnosis.  Even  the  demon- 
stration of  a  tumor  does  not  prove  that  it  is  malignant,  but  the  com- 
bination of  any  two  of  these  three  forms  of  examination  usually  renders 
the  diagnosis  quite  evident.  It  is  not  enough,  however,  to  be  satisfied 
IS 


274  CANCER  OF   THE  STOMACH 

with  the  statement  that  the  patient  has  a  cancer  of  the  stomach.  The 
location  of  the  growth  must  be  determined,  in  reference  to  either  radical 
or  palliative  operation,  and  the  extent  to  which  the  disease  has  invaded 
other  parts  must  be  determined  before  submitting  the  patient  to  the 
pain  and  anxieties  of  a  futile  operation. 

Treatment. — The  treatment  of  cancer  of  the  stomach  should  be 
entirely  surgical.  There  is  no  doubt  that  this  would  be  actually  the 
case  if  we  were  sufficiently  skilful  to  make  the  diagnosis  of  cancer  in 
tmie.  Unfortunately  either  from  our  own  inability  to  interpret  symp- 
toms correctly  or  because  the  patients  come  to  us  in  a  too  advanced 
stage  of  the  malady,  it  usually  happens  that  the  diagnosis  is  too  late 
for  any  other  treatment  than  that  purely  palliative  and  symptomatic. 
In  these  late  cases  diet,  lavage  and  other  medical  means  are  often  of 
service  in  reducing  the  severity  of  the  symptoms  and  improving  the 
general  condition  of  the  patient,  and  in  these  respects  they  are  useful 
as  far  as  they  go. 

Diet. — There  is  no  standard  diet  for  cancer  of  the  stomach.  Each 
patient  must  be  advised  according  to  the  indications  of  his  own  particular 
case.  The  quantity  of  food  at  any  one  meal  is  to  be  determined  by  the 
degree  of  food  stasis  that  may  be  demonstrated  in  the  case,  small 
frequent  feedings  being  advisable  in  those  patients  whose  stomachs 
show  evidence  of  motor  error.  The  quality  of  the  food  on  general 
principles  should  be  bland,  unirritating,  and  wholesome.  Due  regard 
should  be  paid  to  the  caloric  values  to  insure  a  sufficiency  for  body 
gain.  Due  respect  will  have  to  be  paid  to  the  caprices  of  the  appetite, 
and  food  that  is  theoretically  contra-indicated  but  craved  by  the  patient 
may  agree  far  better  than  unai)petizing  articles  of  (het  prescribed  in 
accordance  with  a  definite  routine. 

As  a  rule  meats  are  poorly  digested,  and  for  this  reason  lieef  and  the 
heavier  forms  of  meat  should  be  allowed  sparingly.  Fish  and  chicken 
may  be  given  in  their  stead. 

In  the  advanced  cases  that  come  under  treatment  with  the  history 
of  repeated  vomiting  it  is  usually  best  to  begin  with  a  purely  milk  diet, 
to  which  may  later  be  added  malted  milk,  custard,  junket,  and  the  finer 
cereals.  Later  the  diet  advised  for  the  third  and  fourth  week  of  ulcer 
cure  may  be  given  (see  page  IS)^)). 

Drugs. — Three  classes  of  drugs  may  be  employed. 

1.  Those  Directed  Toward  the  Correction  of  Errors  of  Secretion.  -  If  the 
fasting  stomach  contains  free  hydrochloric  acid  fiuid  in  excess,  or  if 
the  test  breakfast  show  an  alimentary  hy])(Tsecretion,  alkalies  are 
indicated  to  neutralize  the  excess  of  acid.  An\  form  of  alkalies  com- 
monly in  use  nia\'  be  used—  bicarbonate  of  soda,  magnesia  usta,  or  the 
use  of  alkaline  waters,  such  as  Celestins  Vicln-. 


DURATION,   DIACINOSIS,   AND   TREATMENT  275 

When  gastric  analysis  shows  a  diminution  or  absence  in  liy(lrochh:)ric 
acid,  artificial  means  for  digestion  may  be  employed.  Hydrochloric- 
acid  is  often  of  service  given  with  or  directl}'  after  the  meals.  It  may 
be  judicionsly  combined  with  bitter  tonics,  such  as  gentian  or  the  fluid 
extract  of  condurango.  Oxyntin  w^ith  pepsin  (Fairchild)  may  be  given 
in  lO-grain  doses  in  capsule  with  the  meals,  or  tablets  of  acidol  in  the 
same  doses.  Pepsin  as  ordinarily  prescribed  is  often  inert.  Those 
preparations  of  the  ferment  which  are  physiologically  active  have  failed 
in  the  writer's  experience  to  be  of  any  material  service.  More  service- 
able than  pepsin  is  pancreatin  or  pancreon,  preferably  given  admixed 
with  alkaline  powder  in  cases  in  which  hydrochloric  acid  is  absent  from 
the  test  breakfast. 

2.  Drugs  to  Improve  the  General  Nutrition. — There  is  very  little  use 
in  giving  iron  or  tonics  or  in  giving  bitters,  such  as  condurango,  to 
improve  the  appetite,  and  yet  these  drugs  are  prescribed  not  because 
we  expect  any  good  from  their  use,  but  because  they  serve  to  buoy 
up  the  patient  and  to  allay  in  part  the  anxiety  of  the  family. 

3.  Drugs  to  Relieve  Pain. — Pain  may  be  relicAed  in  the  hyperacid 
cases  by  the  use  of  alkalies,  as  in  the  case  of  ulcer.  The  pain  that 
is  due  to  increased  peristalsis  from  pyloric  closure  is  best  treated  by 
lavage,  by  regulation  of  the  diet,  and  by  the  use  of  olive  oil  before 
meals.  A  very  useful  preparation  is  a  3  per  cent,  solution  of  anesthesin 
in  olive  oil,  the  dose  of  which  is  one  to  two  tablespoonsful  before  eating. 
Orthoform  does  not  relieve  the  pain  of  cancer  as  it  does  the  pain  of 
ulcer.  x\tropine  as  a  controller  of  pain  has  not  been  of  service  in  the 
writer's  cases.  Sooner  or  later  we  are  obliged  to  resort  to  opium,  or 
some  of  its  derivatives.  Codeia  presents  the  least  disadvantages  and 
should  be  first  employed.  When  codeia  fails  the  writer  has  relied  upon 
the  following  prescription: 

I^ — Pulv.  opii  denarcot gr.  ss 

Pulv.  aromatic gr.  ivss 

M.  ft.  caps.  no.  j. 

Sig. — One  two  or  more  times  a  day  for  pain. 

It  has  seemed  as  though  opium  in  this  form  was  more  easily  tolerated 
than  was  morphine.  In  very  severe  cases  reliance  will  have  to  be  placed 
upon  morphine  given  hypodermically. 

Lavage. — Lavage  is  indicated  when  food-stasis  exists  and  should  be 
repeated  daily  either  before  breakfast  or  late  in  the  afternoon  before 
the  last  meal  of  the  day.  The  greatest  gain  derived  from  lavage  is 
the  improvement  in  subjective  symptoms.  The  patients  feel  better, 
eat  better,  and  suffer  less  discomfort  from  their  meals.  When  no  actual 
stasis  can  be  demonstrated,  lavage  may  be  of  some  i)enefit  without 


276  CANCER  OF  THE  STOMACH 

our  knowing  why  it  should  do  good.  In  the  majority  of  cases  lavage 
with  plain  water  is  to  be  employed.  The  addition  of  antiseptics  is 
rarely  of  service,  although  when  the  mass  is  sloughing  or  the  gastric 
contents  are  foul,  such  indication  may  diminish  the  fetor  and  improve 
the  appetite.  Resorcin,  gr.  x,  or  essence  of  peppermint  in  sufficient 
quantities  to  make  the  lavage  water  pleasantly  aromatic,  has  in  the 
writer's  experience  been  among  the  most  efficient. 

Surgical  Treatment. — It  is  after  all  not  an  objection  to  surgical  treat- 
ment that  the  operative  mortality  is  as  high  as  it  is.  Instead  of  con- 
sidering that  25  or  30  per  cent,  of  patients  die  from  their  operation  we 
should  congratulate  ourselves  that  the  balance  survive  the  operation 
and  are  either  benefited  temporarily  or  stand  chance  of  a  more  or  less 
permanent  cure.  The  mortality  of  surgical  treatment  is  difficult  to 
estimate  because  knowing  that  the  disease  is  inevitably  fatal  without 
an  operation  some  operators  take  greater  chances  than  others,  some 
operate  more  radically  than  others,  and  while  the  more  radical  and 
bolder  operators  have  a  higher  percentage  of  immediate  mortality, 
nevertheless 'they  often  succeed  in  postponing  the  fatal  event.  Accord- 
ingly the  mortality  varies  from  14  to  40  per  cent.,  with  a  general  average 
of  25  per  cent,  as  an  immediate  result  of  operation  for  the  radical  cure 
of  gastric  carcinoma. 

The  surgical  treatment  may  be  either  exploratory,  radical,  or  pal- 
liative. 

Exploratory  incision  is  accompanied  by  a  minimum  of  risk,  and  should 
be  resorted  to  in  every  doubtful  case  in  which  there  is  any  suspicion 
whatever  of  malignancy.  It  is  not  wise  to  tell  the  patient  the  reason 
for  the  operation,  although  some  member  of  the  family  should  be  taken 
into  confidence. 

Radical  operation  is  to  be  done  whenever  feasible,  and  if  any  error 
is  made  it  should  be  by  taking  away  too  much  rather  than  too  little 
of  the  affected  area. 

Palliative  oi)erati()ns  are  indicated  for  the  relief  of  pyloric  stenosis. 
Gastrojejunostomy  in  these  instances  is  frequently  followed  by  a  most 
brilliant  improvement  for  the  time  being.  Not  only  are  the  symptoms 
of  food-stasis  reli('\ed,  but  the  patients  gain  in  weight  and  appetite, 
and  e\en  in  extensive  growths  the  pain  may  liecome  almost  negligible. 
It  not  infrequently  happens  that  after  such  a  gastrojejiniostomy 
for  malignant  stenosis  the  patient  will  eat  everything  with  impunity, 
will  gain  oO  to  AO  ])ounds  in  weight,  and  will  be  able  to  do  his  daily 
work.  After  a  certain  jx-riod  of  time,  but  often  after  months,  the 
symptoms  will  return  and  the  ])atient  will  suddenly  lose  Hesh  and 
strength   and   die  from   extreme  weakness. 


CHAPTER  VII 
SARCOMA  OF  THE  STOMACH 

Sarcoma  of  the  stomach  is  comparatively  infrequent,  probably  not 
exceeding  1  per  cent,  of  gastric  tumors.  Tilger  in  3500  autopsies  found 
but  a  single  case,  while  Hosch  in  13,387  autopsies  encountered  6  in- 
stances. To  show  how  infrequent  is  the  involvment  of  the  stomach 
in  sarcoma,  of  12(33  autopsies  on  sarcomatous  patients,  compiled  from 
pathological  records  in  Munich  and  Berlin,  by  Wilde  and  Gurlt,  there 
was  not  a  single  instance  in  which  the  stomach  was  involved.^  Fenwick, 
however,  considers  that  sarcoma  is  somewhat  more  frequently  observed 
than  is  supposed,  and  estimates  that  5  to  8  per  cent,  of  gastric  tumors 
are  of  this  nature,  basing  this  rather  high  estimate  upon  the  fact  that 
in  the  earlier  days  of  accurate  pathology  neoplasms  were  regarded 
as  cancer  that  should  have  been  correctly  diagnosticated  as  sarcoma. 
His  estimate  is  corroborated  by  Perry  and  Shaw  who  found  4  cases 
of  sarcoma  in  50  instances  of  malignant  disease  of  the  stomach. 

The  writer  believes  that  this  estimate  of  Fenwick's  is  entirely  too 
high,  for  in  1910  only  123  cases  were  reported,  and  Gossett,^  has  been 
able  to  collect  but  171  cases  of  gastric  sarcoma. 

Both  sexes  appear  to  be  equally  susceptible  to  the  disease. 

Sarcoma  shows  a  more  even  distribution  among  the  ages  than  cancer, 
and  among  young  subjects  lymphosarcoma  and  round-cell  sarcoma 
are  especially  frequent.  It  is  wrong,  however,  to  consider  that  this 
form  of  neoplasm  is  confined  to  the  young,  as  it  is  actually  more  com- 
mon in  adult  years.  The  age  of  the  patients  recorded  by  Ziesche  and 
Burgaud  is  as  follows: 

Ziesch6.  Bvirgaud. 

Age.  Cases.  Case.s. 

0  to  10  years 2  2 

10  to  20  years 11  7 

20  to  30  years 18  10 

30  to  40  years 15  14 

40  to  50  years 29  19 

50  to  60  years 24  IS 

60  to  70  years 12  10 

70  to  SO  years  .      .      '. 6  5 

117  85 

^  These  writers  presented  separate  reports  from  their  respective  laboratories. 
The  two  sets  of  statistics  are  here  combined. 
2  La  Presse  Medicale,  March  16,  1912. 


27S 


SAm'()^[A    OF   THE  STOMACH 


Pathology. — Gastric  sarcoma  may  occur  cither  as  a  circumscribed  or 
a  diffuse  infiltration,  which  ahnost  invariahly  is  the  case  with  lympho- 
sarcoma and  the  round-cell  sarcoma,  or  it  may  appear  as  a  tumor, 
either  in  the  wall  of  the  stomach,  or  projecting  as  a  j^ear-shaped,  pedun- 
culated growth  into  the  lumen  of  the  stomach,  or  outwardly  into  the 
greater  or  lesser  peritoneal  ca\'ity,  but  connected  with  the  stomach 
wall  by  a  pedicle.  The  tendency  to  grow  inwardly  or  outwardly 
has  led  to  the  subdivision  of  such  pedunculated  growths  into  the 
endogastric  and  the  exogastric  form,  and  these  growths  are  largely 
made  up  of  the  spindle-cell  form.  The  newgrowth  usually  arises 
in  the  submucosa  or  the  muscularis,  the  mucous  membrane  being 
involved  late  in  the  disease,  if  at  all.  In  many  cases  the  mucous  mem- 
brane slides  normally  over  the  tumor  mass,  though  in  some  instances 
it   mav  be  adherent  and   sloughing. 


Fic;.  4.- 


Sarcoma  of  the  pyloric  ciiil  of  stoiiiacli.  Tlic  tumor  is  fairly  sharply  o\itlincd  at  T,  T;  main  ma.s3 
of  tumor  is  socn  at  (';  D,  (luodcnuiii.  (Kroin  the  Pathological  Museum,  Mt.  Sinai  Hospital,  New 
York.) 


.Sarcoma  of  the  stomach  ina\  be  primary  or  secondary.  Primary 
sarcoma  is  the  ordinary  form,  and  is  nine  times  as  fre(iuent  as  the 
secondary  form.  .Secondary  sarcoma  is  usually  melanosarcoma  or 
lymphosarcoma.  The  spindle  form  is  rare.  Secondary  deposits  may 
be  metastatic,  arising  from   a   i)riniary  growth   in   the  neck,   pharynx. 


I'ATHoiJxn' 


279 


rectum,  or  in  the  retroiHTitoneal  tissues,  or  in  other  j)arts  of  the  hody, 
or  they  may  occur  as  ])art  of  the  process  of  general  lymphosarcomatosis 
of  the  gastro-intestinal  tract.  In  other  instances  the  seconchiry  nodules 
represent  the  internal  manifestations  of  Ilodgkin's  disease. 


Lymphosarcoma  of  the  stomach.  D,  duodenum;  S,  stomach;  P,  pyloric  ring;  T,  tumor.  At  A 
it  is  seen  emerging  from  the  mucous  membrane.  (From  the  Pathological  Museum,  Mt.  Sinai  Hospital, 
New  York.) 


All  varieties  of  sarcoma  may  occur  in  the  stomach.  In  117  cases 
collected  by  Ziesche  and  Davidsohn  the  following  varieties  were 
encountered. 

Round-cell  sarcoma 35  cases 

Spindle-cell  sarcoma               26  cases 

Lymphosarcoma 23  cases 

Myosarcoma 20  cases 

Mixed  sarcoma 2  cases 

Angiosarcoma 5  cases 

Lymphangio 3  cases 

My.xosarcoma 3  cases 

The  frequency  in  which  these  varieties  occur  is  given  somewhat 
differently  by  Fenwick,  who  has  found  round-cell  sarcoma  in  62 
per  cent,  of  the  cases,  and  considers  that  myosarcoma  is  extremely 
rare. 

The  situation  of  the  growth  is  more  widespread  than  is  the  case  with 
cancer,  as  is  seen  in  the  analysis  of  the  implantation  of  the  growth  in 
100  cases  reported  by  Ziesche  and  Davidsohn: 

Pylorus 25  cases 

Greater  curvature 22  cases 

Diffuse  infiltration 18  cases 

Posterior  wall ....      15  cases 

Lesser  curvature .11  cases 

Anterior  wall 6  cases 

Fundus       ....  .1  case 

Cardia 2  cases 


280 


SARCOMA   OF  THE  STOMACH 


Tumors  arisinjj;  from  the  greater  curvature  are  often  pediculated 
and  extend  outwardly  from  the  stomach,  assuming  the  exogastric  form. 

Although  25  per  cent,  of  sarcomas  involve  the  pylorus,  actual 
obstruction  of  that  orifice  is  somewhat  unusual. 

The  size  of  the  growth  varies  from  nodules  barely  visible  to  the  naked 
eye,  up  to  large  tumor  masses  the  size  of  a  child's  head,  or  even  larger, 
and  often  weighing  over  twelve  pounds. 

Various  degenerations  of  the  growth  may  occur.  Of  these  hemor- 
rhage into  the  tumor  substance  and  cystic  degeneration  are  the  most 
frequent.  Some  of  the  cysts  of  the  larger  sarcomas  may  contain 
several  liters  of  fluid. 

Metastases  are  not  only  less  frequent  than  in  cancer,  but  are  less 
liable  to  be  multiple.  There  is,  moreover,  not  the  same  tendency  to 
invade  contiguous  parts  by  direct  extension,  as  is  the  case  with  cancer. 
Metastases  are  more  common  in  the  round-cell  sarcoma  and  lympho- 
sarcoma than  with  the  spindle-cell  form. 

According  to  Fenwick,  metastases  are  found  in  70  per  cent,  of  the 
round-cell  variety : 

Lymph  glands 50  per  cent. 

Kidneys .28  per  cent. 

Liver 

Ovaries 

Pancreas 

Adrenals 

Oment  um 

Skin  nodules 

Lungs 

Diaphragm 

Pleural 

Esophagus 

Intestines 

Mesentery 

Again  we  have  a  difference  between  Fenwick's  and  Ziesche's  figures, 
for  of  84  cases  of  metastases  reported  by  these  latter  writers,  including, 
however,  all  varieties  of  sarcomatous  growths,  there  were  involved: 

Lj'mph  glands 23  cases 

Liver 
Intestines 
Ovary 
Mesentery 


•  each 14  per  cent. 


12  per  cent. 


each 


7  i)er  cent. 


Pancreas 
Skin  nodules 
Kidney 
Diaphragm 
Bones    . 
Spleen 
Scattered    . 


IS  cases 
7  cases 
0  cases 
5  cases 
4  cases 
4  cases 
3  cases 
3  cases 
3  cases 
2  cases 
7  cases 


SYMPTOMS  281 

It  is  interesting  to  note  the  large  proportion  of  cases  showing  metas- 
tatic deposits  in  the  skin.  These  skin  metastases  vary  in  size  from  a 
head  of  a  pin  to  a  bean,  and  they  may  l)e  excised  and  examined, 
establishing  the  diagnosis. 

In  a  few  instances  the  neoplasm  has  implanted  itself  on  the  site  of 
an  nnhealed  ulcer,  and  occasionally  sarcoma  of  the  stomach  has  fol- 
lowed local  injury,  as  in  the  case  of  Brooks,  where  sarcoma  developed 
in  the  cicatrix  of  a  bullet  wound  of  the  lesser  curvature.  Sarcomatous 
degeneration  of  myoma  or  fibromyoma  of  the  stomach  may  occur 
and  these  mixed  forms  often  attain  considerable  proportions. 

Symptoms. — The  symptoms  are  general  and  local. 

General  Symptoms. — Cachexia  is  usually  well-marked  early  in  the 
disease,  and  constitutes  a  most  striking  feature  of  the  complaint. 
Progressive  loss  of  flesh  with  failure  of  physical  powers  is  usually  con- 
spicuous even  in  the  early  cases,  and  is  especially  noticeable  when 
a  round-cell  growth  has  involved  the  pylorus.  Anemia  is  always 
present,  and  gradually  increases,  so  that  the  pallor  may  be  as  marked 
as  that  met  with  in  pernicious  anemia.  The  blood  shows  the  character- 
istics of  the  chloranemia  or  even  the  chlorotic  type  of  anemia.  The 
hemoglobin  may  be  reduced  to  15  or  even  10  per  cent,  of  the  normak 
The  number  of  the  red  cells  is  reduced  but  not  in  the  same  ratio.  In 
one  of  Mange's  cases  there  were  4,000,000  reds  and  30  per  cent, 
hemoglobin.  Leukocytosis  occurs  only  with  complications  or  with  the 
ulceration  of  the  mass. 

Pyrexia  may  be  observed  in  young  subjects  or  in  those  in  which 
the  neoplasm  grows  rapidly  or  undergoes  degeneration.  The  febrile 
reaction  is  apt  to  be  low — 99°  to  101° — but  continuous.  Sharper 
attacks  of  fever  accompany  the  development  of  complications.  Albu- 
minuria is  present  in  about  one-sixth  of  the  cases,  especially  in  the 
round-cell  variety,  and  usually  indicates  metastases  in  the  kidney. 

While  these  general  symptoms  are  commonly  enough  observed  in 
the  majority  of  sarcomas,  there  occur  more  benign  forms  in  which  the 
general  symptoms  caused  by  the  neoplasm  are  slight  or  negligible, 
even  though  the  growth  has  attained  considerable  size.  This  is  especially 
the  case  with  exogastric  myosarcoma.  It  not  infrequently  happens 
that  a  mass  is  discovered  by  physical  examination  which  has  given 
given  neither  general  nor  gastric  symptoms  of  sufficient  importance 
to  arouse  suspicion  of  the  disease.  Cantwell  reports  finding  such  a 
growth  weighing  12  pounds  which  had  given  absolutely  no  symptoms. 

Local  Symptoms. — There  is  practically  no  difference  between  the 
local  symptoms  of  sarcoma  and  cancer.  In  the  earlier  stages  indigestion 
is  complained  of  in  a  vague  and  indefinite  way,  and  affords  no  clue  to 
the  diagnosis.    Especially  is  this  apt  to  be  the  case  with  the  exogastric 


282  I^ARCOMA   OF   THE  STOMACH 

myosarcoma.  Many  of  these  exofj;astri('  jirowths  ^ive  only  the  physical 
signs  of  an  abdominal  tumor  of  unknown  nature  and  of  unknown 
attachment,  and  may  gWe  no  symi)toms  until  the  occurrence  of  such 
complications  as  adhesions,  torsions,  hemorrhages  into  the  tumor, 
suppuration  of  the  tumor,  or  metastases.  \'omiting  is  more  rare  than 
with  cancer,  and  is  a  late  symptom  unless  the  pylorus  be  involved  by 
a  diffuse  growth. 

Although  the  pylorus  is  frequently  involved,  the  vomiting  is  rarely 
characteristic  of  pyloric  stenosis.  Hemorrhages  are  somewhat  rarer 
than  with  cancer,  although  copious  and  sudden  hematemesis  may  be 
the  first  indication  of  disease. 

Hematemesis  seems  to  be  less  common-  in  the  round-cell  variety, 
which  rarel\-  causes  ulceration  of  the  mucosa,  than  in  the  spindle-cell 
form,  in  which  hematemesis  is  quite  frequently  observed.  It  is  some- 
what difficult  to  explain  the  frequency  of  hematemesis  in  these  exogastric 
tumors,  as  the  mucous  membrane  corres})onding  to  the  attachment 
of  the  pedicle  is  usually  intact. 

Pain  is  a  prominent  symptom,  being  absent  in  but  4  per  cent,  of  150 
cases  reported  by  Ziesche  and  Davidsohn,  although  it  was  not  com- 
plained of  in  25  per  cent,  of  Fenwick's  series.  There  may  be  a  sense 
of  fulness  and  oppression  after  eating,  or  actual  pain  either  dull  and 
aching  in  character  or  sharp  and  cramp-like.  Sudden  colicky  par- 
oxysmal pains  may  occur  closely  resembling  those  of  renal  or  biliary 
calculus.  wSevere  and  continuous  pain  with  exacerbations  of  greater 
severity  after  eating  usually  indicates  ulceration  of  the  neoplasm,  or 
its  extension  into  the  pancreas  or  retroperitoneal  tissues.  This  sudden 
and  continuous  pain  was  noted  in  15  per  cent,  of  Fenwick's  collected 
cases.  Solid  exogastric  sarcomas,  chiefly  of  the  fibro-  or  fibromyoma- 
tous  forms,  rarely  give  actual  pain  until  the  growth  is  well  advanced, 
but  are  rather  accompanied  by  a  dragging  sense  of  weight,  aggra\ated 
by  exercise  and  relieved  by  recumbency. 

The  appetite  fails  as  early  as  with  cancer,  although  the  desire  for 
food  may  be  retained  throughout  the  disease. 

Symptoms  of  volvulus  may  appear,  occasioned  by  the  torsion  of  the- 
stomach  on  its  longitudinal  axis  from  the  mechanical  weight  of  an 
exogastric  growth,  but  this  complication  is  less  frequent  w^ith  sarcoma 
than  with  l)enign  tumors,  such  as  fibromas  or  myoma,  as  in  sarcoma 
adhesions  are  more  readily  formed  which  serve  to  hold  the  tumor  mass 
in  place  and  to  pre\'ent  freedom  of  movement  downward. 

Gastric  Analysis,  (lastric  analysis  is  practically  that  of  cancer,  so 
that  a  differential  diagnosis  by  this  method  of  examination  is  quite 
impossible. 

Few  examinations  of  the  fdsiiiKj  sioituich  seem  to  have  been  made 


I'll)' SI  CM.   SKISS  283 

in  the  recorded  cases.     Extreme  dej^rees  of  food-stasis  are  more  rarely 
observed  than  in  cancer. 

Test  hrcakfd.si  shows  the  same  variations  as  in  cancer.  Of  18  cases 
reported  by  Ziesche  and  Davidsohn  in  which  gastric  analyses  were 
made,  normal  chemical  reactions  were  present  in  7.  Hydrochloric  acid 
was  absent,  lactic  present  in  6,  both  acids  present  in  0,  both  acids 
absent  in  3.  Oppler-Boas  bacilli  are  frequently  found  in  the  gastric 
contents. 

Physical  Signs. — A  palpable  tumor  was  found  in  ()6  out  of  72  cases 
in  Ziesche's  and  I)a^'idsohn's  series.  These  observers  group  all  varieties 
of  sarcoma  together  and  compile  their  statistics  from  the  admixture. 

Fenwick  separates  round-cell  from  the  fibrosarcoma  and  myo- 
sarcoma, owing  to  the  difference  in  the  clinical  course  and  physical  signs 
of  the  two  groups.  Round-cell  sarcoma  produces  in  the  majority  of 
instances  a  local  infiltration  of  the  gastric  wall  in  the  region  of  the 
pylorus,  which  may  give  rise  only  to  a  localized  sense  of  resistance  and 
localized  tenderness,  or  to  a  round  or  oval  mass,  smooth,  tender,  and 
usually  quite  freely  movable.  Fenwick  found  that  a  palpable  tumor 
of  the  stomach  was  an  inconstant  sign  of  round-celled  sarcoma  and 
was  observed  in  but  30  per  cent,  of  the  recorded  cases.  On  the  other 
hand,  fibro-  and  myosarcoma  almost  invariably  give  rise  to  tumors, 
often  so  large  as  to  fill  the  entire  abdominal  cavity. 

If  the  growth  arises  near  the  greater  curvature  it  may  be  detected 
in  the  central  or  even  in  the  lower  portion  of  the  abdomen,  a  firm, 
smooth,  and  painless  mass,  quite  freely  movable  in  all  directions.  The 
extreme  mobility  of  exogastric  sarcomas  is  in  striking  contrast  to 
cancer  which  more  rapidly  forms  fixed  adhesions  to  adjacent  viscera. 

The  physical  signs  of  pyloric  obstruction  may  be  frequently  elicited, 
dilatation  of  the  stomach,  succussion  sounds  audible  at  a  time  when 
the  viscus  should  be  empty,  and  occasionally  gastric  stift'ening,  ^'isible 
peristaltic  waves,  and  other  phenomena  of  hypertonus.  Extreme 
degrees  of  pyloric  stenosis  are,  however,  rarely  encountered,  for  although 
submucous  infiltration  of  the  pyloric  canal  is  not  uncommon  in  the 
round-cell  sarcoma,  it  does  not  seem  to  interfere  with  the  patency 
of  the  orifice  as  much  as  one  would  expect. 

Enlargement  of  the  spleen  so  that  the  edge  is  distinctly  palpable 
just  beyond  the  line  of  the  costal  arch  occurs  in  about  12  per  cent, 
of  all  cases,  being  due  to  hyperemia  and  hypertrophy  of  the  viscus 
rather  than  to  metastases  in  its  substance.  Splenic  enlargement  may  be 
of  slight  service  in  diflFerentiating  sarcoma  of  the  stomach  from  cancer. 
It  should  be  remembered  that  in  a  few  instances  a  diffuse  round-cell 
infiltration  of  the  greater  part  of  the  entire  stomach  wall  has  been 
palpable  as  a  tumor  mass  projecting  from  under  the  free  border  of  the 


284  SARCOMA   OF  THE  .STOMACH 

ribs  into  the  hypochrondriinn,  and  lias  been  mistaken  for  splenic 
enlargement. 

Kundrat  has  called  attention  to  the  aid  afforded  in  diagnosis  by  the 
presence  of  enlarged  tonsils  and  occasional  swelling  and  nlceration 
of  the  follicles  of  the  tongue.  These  phenomena  have  been,  however, 
noted  in  very  few  of  the  recorded  cases. 

^Metastatic  deposits  in  the  skin  constitute  an  important  feature  of  the 
disease  in  about  one-eighth  of  the  cases.  The  nodules  may  appear  about 
the  umbilicus  or  scattered  over  the  abdomen,  chest,  and  back.  At 
first  they  are  freely  movable,  but  after  a  time  they  tend  to  become 
adherent  to  the  skin  and  may  even  ulcerate.  They  should  always  be 
searched  for  in  doubtful  cases,  excised  and  examined. 

Enlargement  of  the  supraclavicular  glands  is  rare  compared  with 
cancer.  In  one  instance  the  diagnosis  was  made  by  the  discovery  of 
a  secondary  nodule  in  the  rectum.  Ascites  may  appear  and  obscure 
the  abdominal  signs  of  disease,  but  this  complication  is  relatively  in- 
frequent compared  with  cancer,  as  it  occurred  in  less  than  3  per  cent, 
of  the  reported  cases. 

Duration. — Duration  depends  largely  upon  the  particular  variety 
of  sarcoma  in  question.  Generally  speaking  the  duration  is  longer 
than  in  cancer,  as  the  tumor  is  less  malignant  in  character,  shows  less 
tendency  to  direct  invasion  of  neighboring  parts,  a  diminished  tendency 
to  form  metastases,  and  even  with  pyloric  implantation,  rarely  gives 
rise  to  extreme  stenosis  with  its  attendant  exhaustion  and  emaciation. 

The  average  duration  of  life  with  small-cell  sarcoma  is  about  one 
and  one-half  years,  with  spindle-cell  growths  over  two  years,  while  in 
the  exogastric  forms  of  fibro-  and  myosarcoma  life  may  be  prolonged 
three  to  five  years. 

Death  usually  results  from  anemia  and  exhaustion,  and  is  often  pre- 
ceded bj'  a  semicomatose  state  extending  over  several  days. 

Perforation  of  the  stomach  and  general  peritonitis  occurs  in  about 
10  per  cent,  of  the  round-cell  growths,  far  more  rarely  in  the  other 
forms.  Owing  to  the  absence  of  extensive  adhesions  incomplete  per- 
foration and  perigastric  abscess  are  exceptional.  Fatal  hemorrhage  is 
rare. 

Diagnosis. — Exogastric  growths  with  indefinite  symptoms  may  be 
mistaken  for  ovarian  tumors,  mesenteric  or  j^ancreatic  cysts,  or  any 
of  the  known  forms  of  abdominal  tumors.  An  ex])loratory  incision  is 
usually  necessary  to  reveal  the  ciiaracter  of  the  growth  and  accurately 
locate  its  attachment. 

When  cachexia,  anemia,  and  gastric  symptoms  are  present  it  is  quite 
evident  that  we  are  dealing  with  a  disease  of  malignant  nature,  and  the 
point  to  be  decided  usually  is  the  difTcrentiation  of  the  disease  from 


TREATMENT  285 

cancer.  Sarcoma  may  be  suspected  sIkhiIcI  the  patient  t)e  under 
thirty-five,  and  the  younger  the  patient  the  greater  the  probability 
that  the  disease  is  sarcomatous  in  character.  Low  continuous  fever  is 
more  common  with  sarcoma  than  with  carcinoma.  I^ilargement  of 
the  spleen  is  also  more  frequent.  Large,  fixed  nodular  tumors  due  to 
invasion  of  omentum  and  other  neighboring  parts,  and  extensive 
metastases  of  the  liver  are  indicative  of  cancer  rather  than  of  sarcoma. 

The  difTerential  diagnosis  is  almost  invariably  quite  impossible, 
nor  does  it  matter  in  the  least  whether  a  diagnosis  between  cancer  and 
sarcoma  is  made  before  operation,  as  the  operative  indications  are 
identical  in  the  two  conditions. 

Treatment. — Treatment  is  that  of  cancer.  Early  exploration  should 
be  advised  in  suspected  cases,  and  if  possible  free  removal  of  the 
growth  should  be  attempted.  Extensive  round-cell  infiltration  of  the 
stomach  wall  naturally  renders  complete  removal  an  impossibility, 
but  circumscribed  infiltrations  and  large  pedunculated  tumors  that 
involve  by  their  pedicle  attachment  a  comparatively  small  area  of  the 
gastric  wall,  are  favorable  for  extirpation. 


CHAPTER   VIII 

BENIGN  TOIORS  AND   FOREIGN  BODIES 

BENIGN    TUMORS    OF    THE    STOMACH 

I.\  arlditioii  to  the  malignant  tumors  already  described,  one  occasion- 
ally meets  with  benign  gastric  neoplasms.  These  tumors  are  rare,  and 
are  more  interesting  as  pathological  curiosities  than  as  clinical  condi- 
tions. In  fact,  a  large  proportion  of  the  reported  cases  were  accidental 
discoveries  at  autopsy  in  patients  who  had  no  gastric  symptoms  during 
life.  An  increasing  number  are  being  found  at  operation  in  modern 
surgery,  and  in  a  fair  number  there  have  been  definite  symptoms  refer- 
able to  the  stomach.  However,  these  symptoms  merely  indicate  that 
the  stomach  is  the  seat  of  the  patient's  trouble.  They  in  no  way  indi- 
cate that  one  has  some  rare  form  of  benign  tumor  to  deal  with.  Prac- 
tically all  of  the  various  symptoms  which  have  been  reported  in  these 
cases,  would  most  naturally  be  interpreted  as  being  caused  by  some 
more  common  gastric  trouble,  ^'ery  rarely  a  piece  of  the  tumor 
recovered  from  the  stomach  by  vomiting  or  the  tube  may  furnish  a 
diagnosis. 

The  existence  of  a  palpable  gastric  tumor  which  has  existed  long 
enough  to  rule  out  the  possibility  of  malignancy  may  offer  a  clue; 
but  here  one  has  difficulty  in  ruling  out  a  hyperplastic  inflammatory 
mass,  and  it  is  often  exceedingly  difficult  to  be  sure  that  a  given  tumor 
mass  is  connected  with  the  stomach. 

Fibromyoma.  \'arious  cases  of  fibroma  and  myoma  of  the 
stomach  have  been  reported,  but  as  these  tumors  almost  invariably 
show  both  fibrous  and  muscular  tissue  in  varying  proportions,  it  is 
better  to  consider  them  under  one  group — fibromyomas.  The  condi- 
tions are  very  much  the  same  as  with  similar  tumors  of  the  uterus, 
in  which  all  neoplasms  showing  fibrous  and  muscular  tissue  are  referred 
to  as  fibromyomas.  One  does  not  ordinarily  use  the  terms  fibroid, 
fibroma,  or  myoma. 

Attention  was  first  called  to  these  tumors  in  17()1  by  Morgagni.' 
In  I  SOS,  Steiner-  reported  21  cases.  To  this  number  I)ea\er  and 
Aslihurst'*  have  added  2S  cases. 

'  I)c  Soil,  ct  Caus.  Morb.  Epist.,  xix,  Art.  .58,  Vonctiis,  ITfil.  Tmno  i,  f.  191. 
-  Mcitr.  ■/..  klin.  Chir.,  1898,  xxii,  1,  407. 

■'  Surjicry  of  the  I'ljpcr  .Mxloiiicii,  1908,  i,  1\  1. 


BENIGN   TUMORS  OF   THE  STOMACH 


287 


These  tumors  arise  in  the  muscuhir  coats  of  the  stomach  and,  accord- 
ing as  to  whether  they  grow  toward  the  interior  of  the  stomach  or 
externally,  arc  divided  into  two  fairly  rlistinct  forms. 


Papilloma  of  stomach  at  the  pylorus.  The  tumor  (T)  has  a  broad  pedicle,  not  shown  in  the  picture. 
The  tumor  is  so  situated  that  it  causes  considerable  obstruction  of  the  pylorus  (P).  D,  duodenum. 
(From  the  Pathological  Museum,  Columbia  University,  New  York.) 

Fig.  48 


r^wfTTpnmrTTjHrrniiqfnijnMjiiH|iiM|nii|iir 

o'm-M       1  Z  3  41  5I 

1 


O       INCHES 


I  M  I  I  I  I  I  It  i  I  I  I  1  i  n  i  t  t!  I  I  !  I  I  I  j  i  I  t. 

Fibroma  of  stomafh.       .1,  filiniiiia ;  H.  slni^ini:  iioi-tinii  ri-TiHi\c'il  fm-  niiiTrisi-dpiral    examination. 
(From  the  Patliolofriral  Mii.seum,  C'oluiiiliia  rnivcrsitN",  New  York.) 


288  BENIGN   TUMORS  AND  FOREIGN  BODIES 

Internal  or  Submucous. — These  tumors  are  generally  round  or  oval 
in  shape,  smooth  or  lobulated,  brownish  or  dirty  white  in  color,  covered 
by  mucous  membrane  and  situated  most  commonly  along  one  of  the 
curvatures,  generally  near  the  pylorus.  They  may  be  pedunculated, 
the  pedicle  being  often  nearly  as  broad  as  the  tumor.  The  pedunculated 
form  may  be  multiple,  while  the  ordinary  form  is  very  rarely  so. 

These  submucous  tumors  are  small,  generally  not  exceeding  an  English 
waliuit  in  size.  They  may  become  ulcerated,  causing  small,  repeated 
bleeding,  or  even  fatal  hemorrhage.  They  may  undergo  cystic  or  myxo- 
matous degeneration,  or  show  malignant  changes,  with  metastases. 

jMicroscopically,  fibromyomas  show  interlacing  bundles  and  whorls 
of  unstriped  muscle  and  fibrous  tissue,  arranged  in  more  or  less  con- 
centric layers.  The  proportion  of  the  two  kinds  of  tissue  varies  greatly. 
The  tumor  is  covered  with  mucous  membrane,  and  may  show  superficial 
ulceration. 

Symptoms. — The  location  of  the  tumor  and  the  condition  of  its 
free  surface  determine  the  character  of  the  symptoms.  When  located 
away  from  the  stomach  orifices,  and  when  not  ulcerated,  these  tumors 
rarely  give  any  symptoms.  If  the  tumor  is  situated  at  the  cardiac  orifice 
the  patient  may  suffer  from  dysphagia,  while  obstruction  at  the  pylorus 
gives  the  symptoms  of  pyloric  stenosis  and  subsequent  dilatation  of 
the  stomach.  The  pedunculated  form  in  this  location  may  act  as  a 
ball  vah^e  at  the  pylorus,  or  even  prolapse  through  the  opening, 
causing  sudden,  violent  attacks  of  pain  and  vomiting,  lasting  from 
a  few  minutes  to  several  hours. 

Ulceration  of  the  tumor  leads  to  hemorrhage,  and  one  has  the  clinical 
picture  of  gastric  ulcer — pain,  hematemesis,  and  melena. 

External  or  Subserous. — While  it  is  possible  for  these  tumors  to  be 
of  small  size,  they  are  generally  much  larger  than  the  preceding 
variety.  They  are  firm,  irregularly  nodular,  and  of  a  yellowish  or  dirty 
white  color.  The  largest  ones  reported  weighed  5400  grams'  and 
6000  grams,-  the  latter  reaching  deeply  into  the  pehis. 

Microscopically,  they  do  not  differ  essentially  from  the  submucous 
form. 

Symptoms. — The  ])rinci))al  symptoms  are  those  of  gastric  distress, 
dragging  pain  from  the  weight  of  the  tumor,  and  more  uncommonly, 
those  due  to  some  mechanical  obstruction  by  the  tumor.  There  have 
been  several  cases  reported  in  which  such  tumors  caused  volvulus  of 
the  .stomach. 

On  examination  it  is  often  possible  to  palpate  a  tumor  in  the  abdomen. 
It  is  not  always  easy  to  determine  whether  it  arises  from  the  stomach. 

'v.  Erifich,  Oritralhl.  f.  all};.  Patli.,  ISUr,,  p.  240. 
2  Perls  and  Xeolscn,  Alijj;.  Path.,  Stuttgart,  1S86. 


HKMCX   TIMORS  OF   THE  STOMACH  2X0 

Trratiiwnt. — ()i)erative  procedures  should  be  undertaken  whenever 
a  (Ha^nosis  can  he  made  and  the  tumor  removed,  either  by  excision  of 
that  part  of  the  stomach  wall,  or  by  partial  gastrectomy. 

Lipoma. — These  tumors  are  more  uncommon  than  fibromyoma. 
\'irchow'  recognized  their  existence,  and  Cruveilhier-  believed  that  the 
small  ones  were  not  unusual.  Deaver  and  Ashhursf  give  a  list  of  the 
few  reported  cases.  Like  fibromyoma  they  may  exist  as  subserous  or 
submucous  tumors.  The  former  are  apt  to  be  large  and  form  pendulous 
tumors  on  the  external  surface  of  the  stomach,  near  the  greater  curva- 
ture. They  may  cause  dragging  pain  from  the  mechanical  displacement 
of  the  stomach,  and  it  may  be  possible  to  feel  the  tumor  through  the 
abdominal  wall.  The  latter  occur  as  yellow,  rounded  tumors  projecting 
from  the  inner  surface  of  the  stomach  near  its  central  portions.  They 
generally  do  not  exceed  an  English  walnut  in  size.  They  are  covered 
by  mucous  membrane.    They  give  no  characteristic  symptoms. 

At  times  either  variety  is  distinctly  pedunculated,  and  one  very  rarely 
sees  cystic  degeneration.  Under  the  microscope  these  tumors  are  seen 
to  be  composed  of  fatty  tissue.  At  times  there  is  a  fairly  large  amount 
of  fibrous  tissue  scattered  through  the  tumor. 

Treatment. — If  a  diagnosis  can  be  made,  operation  for  the  removal 
of  the  tumor  is  indicated. 

Adenoma. — These  tumors  are  generally  divided  into  the  two  following 
forms: 

Pedunculated  Form. — In  this  variety,  the  rounded,  smooth,  or 
lobulated  tumor  is  seen  attached  to  the  stomach  wall  by  a  pedicle, 
generally  in  the  pyloric  region.  They  are  generally  single.  Occasionally, 
several  of  the  tumors  are  present.  In  color  they  are  brown  or  grayish 
brown,  and  in  consistence  firm.  Chaput*  has  reported  a  solitary  tumor 
of  this  kind  as  large  as  a  fetal  head.  When  multiple  they  rarely  exceed 
a  walnut  in  size.  Fenwick^  mentions  a  case  in  which  four  adenomas, 
each  the  size  of  a  pigeon's  egg,  were  found  attached  to  the  margin  of 
the  pyloric  ring,  causing  partial  obstruction  of  the  orifice. 

On  section  these  tumors  appear  firm  and  smooth.  Occasionally 
small  cysts  are  seen.  ^licroscopically  the  tumor  consists  of  proliferat- 
ing gastric  glands  in  a  connective-tissue  framework,  rich  in  bloodvessels. 
The  mucous  membrane  covering  the  tumor  shows  chronic  interstitial 
inflammation.  It  is  rarely  ulcerated.  There  may  be  enough  fibrous 
tissue  to  warrant  the  name  fibroadenoma. 

1  Path,  des  Tumeurs,  Paris,  1867,  i,  369. 

•  Anat.  Pathol.,  Paris,  1835-42,  Tom.  II,  XXXe,  Livr.,  PI.  II,  Con.sid.  G(5n.  P.  3. 
'  Surgery  of  the  Upper  Abdomen,  vol.  i,  p.  226. 
'  Bull,  et  mem.  Soc.  anat.,  Paris,  1895,  Ixx,  534. 
^  Cancer  and  Tumors  of  the  Stomach,  London,  1902. 
19 


290 


BENIGN   TUMORS  AND   FOREIGN  BODIES 


It  is  exceedingly  difficult  to  distinguish  between  large  adenomas  and 
adenocarcinomas.  The  microscopical  picture  may  be  quite  similar,  and 
only  the  subsequent  course  of  the  disease  can  decide  the  question. 

Polyadenoma ;  Mucous  Polypi  (Gastritis  Polyposis). — This  condition  is 
uncommon.  Fenwick^  found  the  frequency  of  occurrence  to  be  only 
0.2  per  cent.  Ebstein's^  figures,  based  on  600  autopsies,  are  higher, 
2.3  per  cent. 

The  cause  of  the  condition  is  not  definitely  known,  but  the  growths 
seem  in  some  way  connected  with  chronic  gastritis.  It  is  more  frequent 
in  males,  and  is  rare  before  the  age  of  forty.  Menetrier^  found  the 
condition  frequently  associated  with  fibromyoma  of  the  uterus,  and 
atheroma  of  the  large  arteries. 


Fig.  49 


Gastric  polyp. 

A  number  of  cases  have  been  reported  in  insane  or  epileptic  patients. 
In  these  cases  the  disease  developed  early  in  life.'' 

In  an  analysis  of  84  cases,  Fenwick  and  Fenwick  found  the  tumor 
solitary  in  41  per  cent.  In  the  remaining  50  per  cent,  the  number 
varied  from  6  to  200  tumors. 

The  single  tumors  are  generally  located  near  the  pylorus.  The 
multiple  ones  are  widely  distributed  over  the  interior  of  the  stomach, 
but  are  more  pronounced  near  the  pylorus.    The  multiple  tumors  may 


'  Cancer  and  Tunions  of  the  Stomach,  J.  it  A.  Cliurcliill,  London,  1902. 
2  Arch.  f.  Anat.  n.  Phys.,  1864,  p.  94.  '  Arch,  do  Phy.s.,  1888,  ii,  .32. 

*  .Stcvons,  f;!a.snf)w  Med.  .lour.,   lS9fi,  p.  422;  Xornian,   nul)lin  .lour.  Med.  Sci., 
1893,  p.  .346 


HESKiN   TUMORS   OF   THE  STOMACH 


291 


be  arranged  in  small  groups,  or  in  rows  parallel  to  the  long  axis  of  the 
stomach.  The  surrounding  mucous  membrane  may  show  small  begin- 
ning tumors.  The  tumors  in  the  stomach  may  be  only  a  part  of  a 
similar  condition  affecting  the  intestinal  tract. 

The  tumors  are  rounded  or  irregular  in  shape,  more  or  less  broadly 
pedunculated,  and  quite  uniform  in  size,  the  multiple  ones  being 
smaller  than  the  single  variety.  In  color  they  are  dirty  brown  or 
pinkish  brown.  They  are  generally  covered  with  adherent  mucus, 
and  the  surface  is  more  or  less  pigmented.  On  pressure  they  exude 
considerable  slimy  mucus. 

Fig.  50 


\ 


Simple  polyp  of  pylorus.  About  one-half  of  the  growth  was  removed  for  microscopical  section.* 
before  the  picture  was  taken.  It  caused  moderate  obstruction  of  the  pylorus  with  clinical  .'■ymptoms. 
D,  duodenum;  P,  pyloric  valve;  X,  polyp. 

^Microscopically  these  tumors  show  a  central  stalk  of  connective 
tissue,  containing  bloodvessels  and  lymphatic.  Covering  this  one  may 
see  the  delicate  prolongation  of  the  mu.scularis  mucosae.  Surround- 
ing the  central  stalk  is  an  exuberant  growth  of  mucous  membrane, 
the  glands  being  elongated,  tortuous,  and  dilated.  In  many  places 
they  form  cysts  and  are  filled  with  mucus.  The  intervening  mucous 
membrane  generally  shows  chronic  inflammation. 

Menetrier^  describes  a  more  diffuse  form  W'ith  hyperplasia  and  hyper- 
trophy of  all  the  glands  over  a  large  area  of  the  stomach.  To  this 
condition  he  applies  the  name  "polyadenome  en  nappe." 

1  Les  Tumeur.s,  Traitc  de  Path.  Gon.,  Paris,  1899,  iii,  844. 


292  BENIGN   TUMORS  AND  FOREIGN  BODIES 

Symptoms. — These  depend  largely  upon  the  location  of  the  growth. 
Fenwick^  finds  that  in  nearly  one-half  of  the  cases  in  which  the  fundus 
or  central  portion  of  the  stomach  is  affected  no  symptoms  are  observed, 
while  in  the  remainder  there  are  only  symptoms  of  disordered  digestion. 
Gourrand-  and  Quain  and  Beardsley^  report  cases  in  which  a  mucous 
polyp  was  vomited. 

A  large  number  of  the  patients  complain  of  gastric  discomfort  with 
nausea  and  \'omiting.  When  situated  near  the  pylorus,  the  tumor 
may  cause  some  obstruction,  and  if  pedunculated  may  cause  intermittent 
obstruction  and  dilatation,  as  in  the  case  described  by  Bennett.'* 
Stevens''  reports  a  case  of  multiple  polypi  in  a  patient  subject  to  epi- 
leptic fits,  the  aura  always  arising  in  the  stomach. 

An  unusual  case  of  gangrenous  gastritis  from  strangulation  of  a  polyp 
in  the  stomach  is  described  by  INIcCosh.*^  Collier^  reports  a  case  of 
fatal  intussusception  of  the  duodenum,  due  to  a  polyp  in  the  duodenum 
near  the  pylorus.  At  autopsy  there  was  an  enormous  number  of  polyps 
varying  in  size  from  a  pea  to  a  pigeon's  egg,  scattered  throughout  the 
stomach  and  small  intestine. 

In  1908,  Wegele^  described  a  case  of  long-standing  chronic  gastritis, 
in  which  at  every  passage  of  the  stomach-tube  a  small  piece  of  tissue 
was  left  in  the  eye  of  the  tube.  Microscopical  examination  of  this 
tissue  showed  the  picture  of  an  adenoma  with  transition  to  carcinoma 
in  some  places.  At  operation  the  interior  of  the  stomach  was  found 
covered  with  a  large  number  of  papillary,  larger  and  smaller,  soft 
polyps. 

Treatment. — As  the  diagnosis  is  practically  impossible  in  nearl}^ 
every  case,  the  treatment  must  be  entirely  symptomatic.  If  the  symp- 
toms become  very  severe,  operative  interference  must  be  considered. 

Other  Rare  Tumors. — Very  rarely  more  unusual  tumors  are  en- 
countered in  the  stomach.  Webster^  has  reported  an  osteoma  causing 
pyloric  obstruction. 

^lyxomas  and  angiomas  have  been  ()l)served  very  rarely."* 

Occasionalh-  one  meets  with  c\sts  in  the  stomach  wall.    The\'  occur 


'  Loc.  cit.  2  jou,.   fie  jvi^^a.,  Chir.,  Pharm.,  Paris,  1790,  iv,  366. 

'  Trans.  Path.  Soc,  London,  1856-7,  viii,  219. 

*  British  Med.  Jour.,  1900,  i,  241. 

^  CJla-sgow  Mod.  Jour.,  1896,  xlv,  422. 

■■•  .\nnaLs  of  Surgery,  1900,  ii,  6:50. 

'  Trans.  Path.  Soe.,  London,  1S96,  p.  46. 

"  Mittl.  a.  d.  fJreiizfreb.  d.  Med.  u.  Chir.,  1908,  xix,  53. 

*  London  Med.  and  Phy.s.  Jour.,  1827,  N.  R.  ii,  433. 

'"  Ilau.semann,  Ontrall)!.  f.  ;illti.  Path.,   1.S95,  ]>.  717:  Stocki.s,  .Viuiales  de  la  Soc. 
Med.-LoK  de  Helge.,  190.3,  xvi,  61. 


FOREIGN  BODIES  IN   THE  STOMACH  293 

as  sini])l('  retention  cysts  oF  tlic  gastric  glands,  following  trauma,  or  as 
a  degeneration  i)rocess  in  \ari()us  tumors.  Very  rarely  one  meets  with 
a  hx'datid  c\'st.    ]{\'uschius'  has  descrilxMl  a  dermoid  cvst 


FOREIGN    BODIES    IN    THE    STOMACH 

The  accidental  swallowing  of  small  articles  is  not  uncommon  among 
children.  Tin  whistles,  coins,  marbles,  and  small  toys  carried  in  the 
mouth  not  infrequently  disappear  in  this  manner.  In  the  majority 
of  these  instances,  especially  if  the  object  is  without  sharp  projections, 
it  is  passed  through  the  pylorus,  into  the  bowel,  without  symptoms, 
and  eventually  expelled  through  the  rectum.  Instances  are  on  record 
of  the  uneventful  passage  of  an  opened  saftey-pin  through  the  entire 
digestive  tract.- 

]\Iore  rare  are  the  cases  of  the  lodgement  of  foreign  bodies  in  the 
stomach.  They  may  be  of  almost  infinite  variety,  embracing  hair 
balls,  vegetable  masses,  gastroliths,  hardware,  insects,  slugs,  w^orms, 
leeches,  lizards,  and  snakes.  They  may  enter  the  stomach  as  the  result 
of  accident,  insanity,  or  unusual  or  unclean  habits. 

Hair  balls  are  among  the  most  remarkable  of  these.  They  occur 
almost  always  in  young  girls  who  wear  the  hair  long  and  loose,  and  who 
are  usually  of  normal  mentality,  although  they  have  acquired  the  habit 
of  biting  off  or  pulling  out  and  swallowing  hair,  often  unconsciously. 
Some  have  also  a  habit  of  removing  and  swallowing  fibers  from  blankets, 
carpets,  or  any  similar  material  within  reach. 

While  often  strands  of  hair  and  fibers  of  cloth  may  pass  through  the 
entire  digestive  tract  and  be  discovered  in  the  stools,  still  if  ingested 
in  considerable  number  they  show  a  particular  tendency  to  become 
matted  together  in  the  stomach,  forming  masses  of  various  sizes.  At 
first  their  form  is  globular  or  ovoid,  and  they  may  form  a  sort  of  ball- 
valve  in  the  pyloric  end  of  the  stomach.  As  they  increase  in  size, 
their  shape  becomes  that  of  the  interior  of  the  stomach,  almost  com- 
pletely filling  the  cavity,  and  even  with  projecting  processes  into  the 
duodenum,  and  rarely  into  the  esophagus.  For  this  reason,  the  term 
hair  cast  is  more  accurate  in  describing  the  condition  in  the  human 
subject.  They  are  usually  single,  but  there  may  be  one  or  two  smaller 
secondary  masses.  They  are  usually  rather  loosely  woven,  and  of  a 
felt-like  consistency,  never  becoming  as  hard  as  those  commonly 
observed  in  the  stomachs  of  horses,  cows,  and  other  animals. 

^  Adversaria  Anat.,  Decas  Tertia,  I,  "De  Atheromate,"  p.  2;  in  "Opera  Omnia," 
Amstelodami,  1737. 

-  B.  van  D.  Hedges   Med.  Rec,  Marcli  10,  1906,  Ixix,  389. 


294  BENIGN   TUMORS  AND   FOREIGN  BODIES 

The  conditions  prodnced  in  the  stomach  by  the  presence  of  a  hair 
ball  varies  greatly;  as  a  rule  there  are  more  or  less  dilatation,  chronic 
inflammatory  change  in  the  mucosa,  sometimes  with  areas  of  atrophy, 
and  not  uncommonly  with  ulceration,  especially  at  or  near  the  pylorus. 
A  striking  feature  of  many  cases,  however,  is  the  remarkably  normal 
appearance  of  the  gastric  mucosa  after  the  presence  for  years  of  a  large 
hair  ball. 

Perforation  of  the  stomach  or  duodenum  is  not  uncommonly  met 
with.  Instances  are  recorded  of  intestinal  obstruction  caused  by  small 
hair  balls,  or  detached  portions  of  larger  ones.  Papillomas  have  been 
found  to  coexist  in  some  cases,  when  they  were  thought  to  be  the 
result  of  the  chronic  irritation. 

J^egeiahle  balls  are  less  common.  They  may  be  made  up  of  the  skins 
or  stones  of  fruit,,  or  they  may  result  from  the  practice  of  drinking 
mixtures  prepared  from  certain  vegetable  roots  of  supposed  medicinal 
value.  A  case  has  been  reported  in  a  patient  who  ate  not  only  the  inside 
but  the  outside  of  a  cocoanut.^ 

Gastric  concretions,  although  very  rare,  have  been  known  in  men 
whose  desire  for  alcohol  was  so  great  that  they  would  habitually  drink 
shellac,  varnish,  or  other  resinous  substances  in  alcoholic  solution. 

Harduare,  of  \arious  kinds,  is  occasionally  found  in  the  stomachs 
of  insane  patients,  jugglers,  and  sword  swallowers.  The  insane  who 
are  in  the  habit  of  swallowing  foreign  bodies  are  prone  to  select  some- 
thing very  hard  and  often  of  considerable  size.  Those  who  give  ex- 
hibitions of  swallowing  large  hard  articles  are  sometimes  unable  to 
recover  them.  The  nature,  number,  and  A'ariety  of  hard  articles  that 
\vd\e  been  removed  from  a  single  human  stomach  is  almost  beyond 
belief:  Nails,  screws,  pins,  buttons,  bolts,  pieces  of  glass,  false  teeth, 
pocket  knives,  button  hooks,  and  all  manner  of  carpenter's  tools  have 
been  found  lodged  in  some  portion  of  the  stomach,  usually  the  cardiac 
end,  in  which  they  form  a  pouch.  Ulceration  and  ])erforation,  with 
protective  adhesions,  are  particularly  common  with  this  type  of  foreign 
body. 

Livitig  creatures  also  may  live  for  a  time  in  the  human  stomach, 
often  for  a  sufficiently  long  period  to  be  the  cause  of  considerable  gastric 
disturbance.  Among  these  have  been  found  beetles,  butterflies,  moths, 
maggots,  leeches,  caterpillars,  worms,  lizards,  and  frogs.  The  accidental 
swallowing  of  a  snake  has  been  recorded,  but  it  is  improbable  that  these, 
or  any  of  the  amphibise,  live  long  in  the  stomach,  being  vomited  or  passed 
by  rectum.  Intestinal  parasites,  especially  ascaris  lumbricoides,  may 
a.scend  and  inhabit  the  stomach,  but  usually  for  a  short  time  only,  as 

'  Hicliciis  luid  ()(1m;.ts,  liiili.sli  Mod.  Jour.,  Murcli  10,  1912,  p.  OOO. 


FOREIGN  BODIES  IN   THE  STOMACH 


295 


they  are  promptly  vomited.      Fen  wick  has  collected  a  large  series  of 
cases  in  which  living  creatures  were  found  in  the  stomach.^ 

Symptoms. — Small  articles  usually  pass  through  the  stomach  with- 
out giving  any  symptoms.  Even  those  with  sharp  points  safely  pass 
through  both  stomach  and  bowel  in  a  surprisingly  large  proportion  of 
cases,  although  symptoms  of  perforation  may  be  expected  at  any  time 
until  they  are  expelled.  The  a-ray  in  case  the  material  will  cast  a  shadow, 
and  gives  the  most  definite  and  valuable  information  of  the  progress  of 
the  foreign  body  in  its  course  through  the  stomach  and  intestines.  It  is 
often  of  the  greatest  aid  also  in  making  a  negative  diagnosis  in  those 
supposed  cases  of  swallowed  foreign  bod}'  which  are  the  result  of  an 
active  imagination  in  a  child,  or  a  hasty  conclusion  on  the  part  of  a 
terrified  parent. 

Fig.  51 


Hair  ball  removed  from  stomach  of  a  woman,  aged  twenty  years.     (From  the  Pathological  Museum, 
Columbia  University,  New  York.) 


The  development  of  a  hair  ball  in  the  stomach  usually  occurs  in 
patients  who  give  no  history  whatever  suggesting  the  cause  of  the  con- 
dition. It  may  be  attended  by  remarkedly  few  symptoms.  The  size 
which  such  a  mass  can  attain  in  certain  cases  without  noticeably 
interfering  with  the  gastric  functions  is  surprising,  but  sooner  or  later 
there  is  usually  a  more  or  less  prolonged  period  of  indefinite  digestive 
disturbance  which  progresses  to  definite  pain  and  vomiting. 

The  pain  is  most  common  after  meals,  and  may  be  felt  at  first  through- 
out the  abdomen,  later  being  more  localized  in  the  epigastrium  or  left 
hypochondrium,  and  being  increased  by  pressure.  It  may  be  accom- 
panied by  flatulency,  distention,  and  nausea.     The  vomiting  usually 

'  W.  Soltau  Fenwick,  Dyspepsia,  1910,  p.  287. 


296  BEXKIX   TUMORS  AM)  FOREIGN  BODIES 

occurs  at  the  time  of  greatest  pain,  sometimes  regularly  after  every 
meal.  The  vomit  us  when  typical  is  small  in  amount,  acid,  and  may 
contain  bile  or  possibly  blood,  but  almost  never  hair.  Other  less  con- 
stant symptoms  are  coated  tongue,  foul  breath,  and  alternating  diar- 
rhea and  constipation,  and  a  variable  degree  of  anemia.  The  appetite 
is  not  always  aflPected,  and  loss  of  weight  and  strength  do  not  appear 
until  later.  If  ulceration  has  taken  place,  the  picture  may  be  modified 
at  any  time  by  the  symptoms  of  hemorrhage  or  perforation.  Gastric 
tetany  has  occurred. 

The  feature  of  the  physical  examination  is  the  tumor.  When  the 
patient  is  in  the  dorsal  position  the  greater  part  is  usually  to  the  left 
of  the  median  line,  in  the  epigastrium,  and  left  hypochondrium.  It  may 
be  globular,  ovoid,  or  assume  quite  accurately  the  size  and  shape  of 
the  stomach,  and  there  may  be  one  or  two  smaller  secondary  masses. 
Its  mobility  is  a  distinguishing  characteristic  in  cases  without  adhe- 
sions. It  is  smooth,  quite  hard,  feels  close  to  the  abdominal  wall,  and 
gas  may  be  felt  during  palpation.  The  presence  of  tenderness  depends 
chiefly  upon  ulceration. 

In  cases  in  which  the  habit  is  not  corrected  or  the  mass  is  not  removed 
by  operation,  the  condition  is  steadily  progressive.  .  A  case  has  been 
recorded  of  which  the  duration  was  twenty-two  years.  Death  occurs 
most  often  from  inanition,  to  which  the  diarrhea  in  some  cases 
contributes,  or  from  perforation. 

The  chief  difficulty  in  diagnosis  is  that  the  condition  is  so  rare  that 
the  physician  seldom  has  it  in  mind.  Some  of  the  conditions  for  which 
hair  ball  may  be  mistaken  are  gastric  cancer,  displaced  kidney  or 
spleen,  omental  tumor,  and  fecal  impaction.  Retroperitoneal  sarcoma, 
pancreatic  cysts,  and  tuberculous  glands  are  less  apt  to  be  considered 
because  they  are  usually  less  mobile.  The  chief  features  of  hair  balls 
which  are  useful  in  diagnosis  are:  their  occurrence  almost  always  in 
girls  who  wear  the  hair  long,  the  long  duration  of  symptoms,  and  the 
mobility  and  smoothness  of  the  tumor.  The  relationship  of  the  tumor 
to  the  stomach  may  be  shown  by  careful  inflation  of  that  organ,  but 
better  still  by  the  .r-ray  after  the  ingestion  of  bismuth. 

Vegetable  balls  are  even  more  rare  than  hair  balls,  seldom  reach  such 
large  size,  and  occur  in  older  patients  of  both  sexes  from  whom  it  is 
less  difficult  to  obtain  a  history  of  the  causative  habit  or  mental  con- 
dition. The  detachment  of  fragments  and  their  expulsion  per  rectum 
are  more  frequent. 

The  symptoms  in  cases  of  hardware  in  the  stomach  are  seldom  apt 
to  be  characteristic,  and  their  entire  absence  is  often  remarkable.  The 
type  of  patient,  history,  and  .r-ray  are  the  most  usual  aids  to  correct 
diagnosis. 


FOREIGN  BODIES  IN  THE  .STOMACH  297 

Living  creatures  make  their  entrance  into  tlie  stomach  often  as 
larvae  or  ova  which  have  been  deposited  on  food,  either  after  its  prepara- 
tion, or  on  uncooked  articles,  or  from  eating  improperly  prepared  salads 
or  drinking  impure  or  stagnant  water.  Fenwick  cites  a  case  which 
resulted  from  the  habitual  eating  of  clay  considered  sacred  by  a  super- 
stitious young  woman.  Instances  of  these  conditions  are  more  common 
in  tropical  than  in  temperate  climates.  Their  presence  is  usually  made 
known  by  their  discovery  in  the  feces  or  vomitus.  They  produce 
indefinite  gastric  or  intestinal  symptoms,  unusual  sensations,  or  vomit- 
ing with  or  without  persistent  diarrhea.  Fever  is  not  uncommon, 
and  in  children  there  may  be  convulsions.  Those  hysterical  patients 
who  frequently  describe  sensations,  which  they  are  convinced  are  caused 
by  a  living  object  in  the  stomach,  as  well  as  those  who  deliberately 
intend  to  give  a  false  impression  by  adding  insects  or  other  creatures 
to  specimens  of  feces  or  vomitus,  must  be  sharply  differentiated  from 
those  who  actually  harbor  such  objects. 

Treatment. — In  cases  among  children  in  whom  small  foreign  bodies 
have  entered  the  stomach  after  having  been  accidentally  swallowed, 
it  is,  as  a  rule,  unwise  to  administer  emetics  or  cathartics.  A  diet  of 
mashed  potatoes,  with  cream  and  butter,  for  a  few  days  may  have  the 
effect  of  surrounding  the  article  with  a  starchy  coating  which  facilitates 
its  safe  passage  through  the  intestine.  Oil  enemas  may  be  used  if 
necessary  to  secure  bowel  movements.  This  class  of  cases  is  best  treated 
conservatively,  especially  in  infants  and  very  young  children,  in  whom 
the  risk  of  operation  is  relatively  great.  The  patients  should  be  care- 
fully watched,  if  possible  with  the  assistance  of  the  .T-ray,  when  surgical 
intervention  may  be  resorted  to  without  delay  in  case  symptoms  of 
obstruction  or  perforation  arise. 

When  gastric  or  intestinal  symptoms  coexist  wdth  the  habit  of 
swallowing  hair,  but  when  no  tumor  can  be  felt,  detection  and  correc- 
tion of  the  habit  may  be  followed  by  a  complete  disappearance  of  the 
symptoms.  But  in  the  case  of  hair  balls,  vegetable  balls,  or  gastric 
concretions  of  sufficient  size  to  be  palpated  or  of  hardware  lodged  in 
the  stomach,  the  only  treatment  is  operation.  Attempts  at  removal 
by  means  of  emetics  or  cathartics  are  attended  by  too  much  risk  and 
too  little  chance  of  success  to  be  permissible. 

Prophylaxis  is  of  prime  importance  when  habits  resulting  in  the 
ingestion  of  larvae  or  ova  are  detected.  A  thorough  catharsis  may 
result  in  the  expulsion  of  all  of  the  insects  or  animals,  but  when  they 
are  more  resistant  or  numerous,  thymol,  santonin,  or  other  anthel- 
mintic is  necessary. 


CHAPTER   IX 

TUBERCULOSIS  AND  SYPHILIS  OF  THE  STOMACH 

TUBERCULOSIS   OF   THE   STOMACH 

Tuberculosis  of  the  stomach  is  a  disease  of  comparative  rarity,  as 
it  is  present  in  but  0.5  per  cent,  of  all  autopsies,  and  in  but  2.3  per 
cent,  of  the  post  mortems  done  on  those  dead  from  tubercular  disease. 
It  is  somewhat  more  common  in  acute  miliary  tuberculosis  than  in  the 
chronic  forms  of  infection.  Difficulty  in  drawing  conclusions  from  the 
ordinary  postmortem  statistics  as  to  its  frequency  lies  in  the  fact  that 
unless  microscopical  examination  shows  a  typical  tubercular  picture, 
or  unless  tubercle  bacilli  can  be  demonstrated  in  the  tissues,  there  is 
always  a  doubt  whether  the  lesion  is  tuberculous  or  not.  Not  infre- 
quently do  those  affected  with  phthisis  suffer  from  the  ordinary  form 
of  gastric  or  duoflenal  ulceration,  so  that  without  microscopical  or 
bacterial  examination  it  cannot  be  assumed  that  a  particular  ulcera- 
tion found  at  autopsy  in  a  tuberculous  patient  is  a  secondary  infection 
resulting  from  the  pulmonary  complaint,  or  an  independent  and  coexist- 
ing ailment. 

Mode  of  Infection. — 1.  It  is  plausible  to  assume  that  infection  of  the 
stomach  by  the  tubercle  bacilli  would  most  readily  occur  by  the  direct 
contact  of  the  mucous  membrane  by  infected  sputum  arising  from 
tubercular  disease  of  the  upper  air  passages,  or  by  food  that  has  been 
contaminated  by  tuberculous  dust.  It  is  obvious,  however,  that  this 
mode  of  infection  is  not  as  frequent  as  one  would  expect.  The  peris- 
taltic power  of  the  stomach  to  empt>'  itself  is  a  far  more  potent  pro- 
tection against  tubercular  infection  than  is  the  bactericidal  affect  of 
the  gastric  juice,  as  it  requires  twelve  to  eighteen  hours'  immersion  in 
this  secretion  to  destroy  the  bacillus.  The  poverty  of  the  stomach 
in  lymph  follicles  as  distinguished  from  the  abundance  of  this  tissue 
ill  the  intestinal  tract  is  an  additional  reason  why  the  stomach  should 
be  much  less  frequently  affected  than  the  intestine  by  tubercular 
disease. 

2.  The  bacilli  may  infect  the  stomach  wall  through  lymphatic 
vessels  or  through  the  contiguity  of  tuberculous  perigastric  glands.  In 
this  ninniKT   the  stomnch   is   often    in\'()lved    as  a    secondarx'    infection 


TUBKIiCVLOSIS  OF   TJ/K  STOMACH  299 

to  tuberculous  lesions  in  the  intestine  or  peritoneum,  e\'eii  tliou.uii  the 
lungs  be  free  from  all  tubercular  taint. 

In  a  case  reported  by  Clayton  and  Wilkinson,^  there  were  three  case- 
ous glands  in  the  neighborhood  of  the  ulcer,  one  of  which  was  adherent 
to  its  base  and  showed  microscopical  communication  with  it.  A  similar 
case  is  reported  by  Besnier  in  which  a  man  without  pulmonary  com- 
plaint was  found  to  have  tuberculosis  of  his  abdominal  glands,  one  of 
which  had  suppurated  and  had  perforated  into  the  posterior  wall  of 
the  stomach. 

8.  iVrloing  believes  that  infection  through  the  blood  current  is  the 
most  usual  method,  as  he  has  been  able  to  produce  tuberculous  gastric 
and  duodenal  ulceration  by  injecting  bacilli  into  the  blood.  This 
theory  is  further  supported  by  the  fact  that  these  tuberculous  ulcerations 
are  more  frequently  observed  in  acute  disseminated  tuberculosis  than 
in  the  chronic  forms  of  the  disease  in  which  the  process  is  more  localized. 

It  is  a  rarity  to  find  tubercular  disease  of  the  stomach  as  a  primary 
infection,  as  in  almost  all  instances  the  gastric  disorder  is  secondary 
to  or  is  associated  with  tubercular  disease  of  the  lungs  and  upper  air 
passages  or  of  the  intestines  and  peritoneal  tuberculosis  with  involve- 
ment of  the  perigastric  glands.  The  symptoms,  therefore,  of  gastric 
origin  are  frequently  so  intermingled  with  those  of  the  primary  ailment 
that  the  clinical  course  of  the  disease  is  often  involved  and  obscure. 

Nor  can  it  be  affirmed  that  because  a  patient  with  tuberculosis  com- 
plains of  his  digestion  that  the  cause  for  his  discomfort  lies  in  an  organic 
involvement  of  the  stomach  by  any  tuberculous  process.  Tuberculous 
patients  are  apt  to  suffer  from  functional  derangements  of  their  digestion 
either  by  reason  of  failure  of  their  general  strength  or  because  the 
stomach  has  been  overloaded  by  food  or  by  large  quantities  of  milk 
and  cream.  In  other  instances,  chronic  gastritis  with  acute  exacerba- 
tions may  occur,  due  in  all  probability  to  the  toxins  generated  by  the 
primary  disease.  There  are  many  cases  of  acute  phthisis  which  begin 
their  clinical  course  by  excessive  vomiting,  apparently  of  toxic  origin. 
In  more  advanced  cases  it  is  not  unusual  for  atrophy  of  the  mucous 
membrane  of  the  stomach  to  occur.  Tuberculous  patients  who  are 
enteroptotic,  regularly  suffer  from  the  symptoms  of  this  ailment  in  an 
aggravated  form  whenever  they  lose  flesh  and  strength  by  reason  of 
their  pulmonary  complaint.  In  many  cases  one  of  the  abo^•e-mentioned 
types  of  dyspepsia  may  constitute  for  a  time  the  sole  symptom  of  the 
pulmonary  disease,  amending  or  altering  its  type  as  the  pulmonary 
disease  progresses,  and  gradually  subsiding  as  the  tuberculous  process 
becomes  arrested.    These  forms  of  indigestion  must  always  be  excluded 

'  Arch.  Int.  Med.  April,  1905,  p.  S2.5. 


300  TrBERCrLOSIS   AXD  SYPHILIS  OF   THE  STOMACH 

before  we  can  assume  that  the  dyspeptic  comphiints  of  phthisis  are 
due  to  an  actual  infection  of  the  stomach  hy  a  tuberculous  process. 

The  tuberculin  test  is  rarely  of  service,  owing  to  the  presence  of  other 
obvious  tuberculous  lesions  in  other  parts  of  the  body.  The  ophthalmic 
test  and  the  cutaneous  reaction  test  of  von  Pirquet  have  long  since 
been  abandoned. 

Forms. — Aside  from  the  deposition  in  the  stomach  wall  of  miliary 
tubercles  that  occur  with  acute  miliary  tuberculosis,  and  which  are  of 
anatomical  rather  than  of  clinical  interest,  tuberculosis  of  the  stomach 
occurs  in  two   principal   forms: 

1 .  Tuberculous  ulcer. 

2.  Tuberculous  tumors  with  pyloric  stenosis. 

Tuberculous  Ulcers. — The  ulcers  vary  in  size  from  that  of  a  dime  to 
large  irregular  excavations  1§  or  2  inches  in  diameter.  In  the  case  of 
Clayton  and  Wilkinson,  a  large  single  ulcer  was  found  surrounding 
the  esophageal  opening,  9  by  4|  centimeters  in  size.  Any  portions 
of  the  stomach  may  be  involved,  although  the  lesser  curvature  and  the 
pyloric  region  are  its  favorite  seats.  The  edges  are  usually  raised  above 
the  surrounding  tissue,  are  thickened  and  nodulated,  and  often  present 
a  scalloped  appearance.  As  the  disease  process  usually  begins  in  the 
submucosa,  it  may  happen  that  the  edges  are  deeply  undermined.  The 
base  may  be  grayish  or  yellowish,  and  presents  a  granular  aspect  from 
irregular  deposits  of  tuberculous  tissue.  Such  ulcerations  may  be  either 
single  or  multiple.  In  EUis''^  case  8  ulcers  were  found.  The  peritoneum 
covering  the  base  of  the  ulcer  almost  always  exhibits  a  few  miliary 
tubercles,  and  is  not  infrequently  adherent  to  neighboring  parts.  The 
perigastric  glands  seem  regularly  to  be  involved,  either  secondary  to 
the  ulcer  itself,  as  is  the  case  when  infection  has  occurred  through  the 
swallowing  of  sputum  or  contaminated  food,  or  the  inflammation  of 
the  glands  may  be  secondary  to  tubercular  disease  of  the  peritoneum 
or  intestines,  and  through  contiguity  of  tissue  may  cause  a  further 
involvment  of  the  stomach. 

Perforation  into  neighboring  parts  may  ensue.  The  duodenum  has 
been  known  to  be  ])erforated,  forming  a  gastroduodenal  fistula  with 
temporary  relief  from  the  symptoms  of  ])yl()ric  stenosis.  Gastrocolic 
fistulas  have  also  been  noted. 

Symptoms  of  Tuberculous  Ulcer. — In  the  majority'  of  cases  the 
symptoms  of  the  ulcer  itself  are  so  obscured  by  those  of  the  original 
tubercular  disease  that  the  diagnosis  is  unsuspected.  Of  the  gastric 
symptoms  proj)er,  pain,  hemorrhage,  and  perforation  are  the  most 
important. 

'  Now  York  Med.  Jour.,  Marcli  12,  1910. 


TUJiERCI'LOSIS  OF   Till':  STOMACH  301 

Pain. — Pain  is  usually  a  well-marked  symptom  and  resembles  that 
of  the  ordinary  gastric  ulcer  in  ha\'ing  a  fixed  relation  to  the  taking  of 
meals.  The  relief  att'orded  by  eating  is,  however,  less  noticeable  and 
of  shorter  duration  than  is  the  case  with  the  simple  ulcer.  When  the 
peritoneal  coat  is  in\'oh'ed,  pain  may  be  more  constant  and  severe 
and  is  associated  with  well-marked  tenderness  in  the  region  of  the 
stomach.  Kigidity  of  the  upper  abdominal  wall  is  indicative  of  such 
a  peritoneal  involvement.  As  compared  with  the  ordinary  form  of 
ulcer,  the  pain  of  tuberculous  ulceration  is  more  constant,  more  severe, 
and  is  not  marked  b}-  the  intermissions  so  commonly  observed  in  the 
non-tubercular  form.  The  distress,  furthermore,  is  apt  to  occur  sooner 
after  the  taking  of  food  than  is  usually  the  case  in  the  non-tubercular 
form  of  ulceration. 

Hemorrhage. — Hemorrhage  may  occur  both  in  the  visible  and  occult 
form,  but,  as  a  rule,  profuse  hemorrhages  are  rare. 

Perforation. — Perforation  is  not  an  uncommon  event,  and  may  be 
the  first  symptom  that  indicates  the  presence  of  the  ulcer.  If  the 
patient  be  in  a  fair  condition  of  health,  the  symptoms  are  those  of 
perforation  in  its  classical  and  typical  form;  but  should  the  patient  be 
much  debilitated  by  the  tubercular  disease,  the  initial  symptoms  of 
shock  are  less  marked;  but  the  symptoms  of  acute  peritonitis,  never- 
theless, develop  and  death  rapidly  supervenes. 

Tuberculous  Pyloric  Stenosis. — The  deposition  of  tuberculous  tissue 
of  the  hyperplasia  type  in  the  neighborhood  of  the  pylorus  may  result 
in  the  formation  of  a  tumor  in  this  situation  obstructing  the  pyloric 
orifice.  As  a  rule,  this  form  of  tuberculous  deposition  is  rich  in  connec- 
tive tissue,  shows  but  few  giant  cells,  and  contains  but  few  bacilli, 
thus  indicating  an  attenuated  infective  process.  In  some  instances 
this  attenuation  is  so  marked  that  microscopical  examination  fails  to 
reveal  any  apparent  evidence  of  tubercular  nature. 

In  a  case  reported  by  Chalier,^  a  thickening  of  the  pylorus  existed 
without  any  specific  tubercular  change,  and  yet  inoculations  of  the 
guinea-pigs  with  scraps  of  tissue  from  this  neoproduction  resulted  in 
the  death  of  the  animals  from  tuberculosis.  It  is  possible  that  many 
cases  of  fibrous  stenosis  of  the  pylorus  might  be  found  in  this  way  to 
be  of  tubercular  origin.  Chalier  states  that  the  structure  of  the  stenosis 
in  his  case  resembled  so  closely  the  lesions  encountered  in  stenosis 
of  the  pylorus  in  the  newly  born  that  it  suggested  a  possible  similar 
origin  in  the  latter  cases. 

^  Tumeu  inflammatoire  stenosante  du  pj'lore  d'origine  tuberciileuse  (Rapports 
de  rinflammation  avec  I'hypertrophe  tumerus  du  tissue  musculaire  lisse),  J.  Chalier 
and  L.  Novo  Josserand,  Lyon  Chirurgical,  1911,  Tome  vi,  No.  4,  pp.  389-412. 


302  rVBERCULOSIS   AND  SYPHILIS  OF   THE  STOMACH 

Symptoms. — The  symptoms  of  tul^erculoiis  pyloric  stenosis  closely 
resemble  those  of  mtilignant  origin.  Food-stasis  is  commonly  observed, 
as  is  shown  by  the  passage  of  the  tube  in  the  fasting  state  and  by  the 
vomiting  of  the  patient  from  time  to  time  of  food  that  has  been  lying 
in  the  stomach  for  many  hours.  The  pain  and  discomfort  are  those 
ordinarily  observed  in  pyloric  stenosis,  and  do  not  serve  to  differentiate 
the  particular  type  of  contracture. 

Diagnosis. — Gastric  analysis  is  practically  identical  with  that  ob- 
served in  carcinoma  of  the  pylorus.  The  fasting  stomach  contains 
evidence  of  food  remains,  with  or  without  lactic  acid  and  lactic  acid 
bacilli.  Test  breakfast  shows  a  diminution  or  absence  of  free  and 
combined  hydrochloric  acid  and  the  presence  of  lactic  acid  in  appreciable 
amounts.  IMicroscopically  the  Oppler-Boas  bacilli  are  not  infrequent. 
Physical  examination  shows  a  hard,  movable,  elongated,  and  slightly 
tender  tumor  below  the  right  costal  margin  in  the  position  of  the  pylorus. 
A  well-marked  pyloric  squirt  may  be  audible  through  the  stethoscope. 
Should  the  peritoneum  covering  the  tumor  be  the  seat  of  tuberculosis, 
marked  tenderness  and  rigidity  will  be  present. 

Prognosis. — The  prognosis  depends  as  much  if  not  more  upon  the 
extent  of  the  other  tuberculous  lesions  of  the  body  than  upon  those  in 
the  stomach.     Recovery  is  possible,  but  the  chances  for  it  are  slight. 

Treatment. — Medical  treatment  is  not  of  much  avail  in  producing 
any  direct  effect  upon  the  healing  of  the  lesion,  although  some  degree 
of  relief  to  the  distressing  symptoms  may  result  from  careful  manage- 
ment of  the  case.  The  dietetic  rules  are  those  of  ulcer  generally.  Lavage 
may  be  of  service  if  food  retention  should  occur  from  narrowing  of 
the.  pyloric  orifice.  The  results  of  medical  treatment  are,  however, 
most  disappointing,   as  a  rule. 

Operative  interference  is  not  generally  advisable,  unless  to  relieve 
pyloric  obstruction.  Tf  the  diseased  process  at  operation  seems  to  be 
limited  to  the  pylorus,  and  if  the  other  tuberculous  lesions  are  not  such 
as  to  obviously  limit  the  expectation  of  life,  partial  gastrectomy  may 
be  performed. 

P^xcision  of  tuberculous  ulcerations  at  parts  of  the  stomach  other 
than  the  pyloric  portion  is  an  o])eration  not  lightly  to  be  advised, 
although  such  a  process  may  be  justifial)le  if  the  process  is  limited  to 
the  neighborhood  of  the  ulcer,  and  if  the  other  tuberculous  lesions  are 
not  sufficiently  advanced  to  threaten  life  in  the  near  future. 

Of  20  reported  cases  in  which  operations  were  done  for  tubercular 
disease  of  the  stomach,  Dcaver  could  trace  the  end  results  in  IS.  Of 
the  18  patients,  5  died  front  the  operation.  Of  the  remaining  l.'i,  S 
were  traced  to  their  death,  which  occurred  iit  an  average  period  of  eight 
months  after  the  o])eratioii.     One  ])ati<'nt   hxcd   for  three  and  a   half 


SYPHILIS  OF   THE  SrOMACII  303 

years,  finally  succumbing  to  an  abscess  of  the  liver.  In  the  remaining 
four  the  period  of  time  that  had  elapsed  after  the  operation,  at  the  time 
of  their  report,  was  too  short  to  be  conclusive. 


SYPHILIS    OF    THE    STOMACH 

Syphilis  of  the  stomach  occurs  as  a  rare  localization  of  the  visceral 
form  of  late  syphilis,  either  hereditary  or  acquired.  Chiara  found 
specific  lesions  present  in  the  stomach  in  but  3  out  of  242  autopsies 
performed  on  syphilitic  subjects.  Of  these  1  was  hereditary,  2 
were  acquired. 

It  is  estimated  that  there  are  on  record  in  the  neighborhood  of  50 
cases  of  gastric  syphilis.  It  is  probable,  however,  that  the  disease  is 
much  more  frequent  than  this,  and  that  it  is  our  failure  to  correctly 
diagnosticate  the  ailment  that  accounts  for  its  supposed  rarity.  It  must 
be  remembered,  however,  that  ordinary  ulceration  of  the  stomach  may 
occur  in  syphilitic  persons  with  the  same  frequency  as  it  does  in  those 
without  this  constitutional  taint.  Again,  it  must  be  remembered  that 
an  antisyphilitic  treatment  will  favorably  influence  non-specific  affec- 
tions in  syphilitic  patients  by  improving  their  general  health.  Xor 
must  it  be  forgotten  that  a  rigid  course  of  mercury  and  potassium  iodide 
may  so  derange  the  digestion  as  to  produce  symptoms  either  of  chronic 
gastritis  or  of  functional  dyspepsia. 

Allen  A.  Jones  has  called  attention  to  the  frequency  of  neuralgic 
pains  in  the  region  of  the  stomach  in  syphilitic  patients.  These  he 
considers  to  be  of  functional  nature,  due  to  the  disturbances  in  the 
general  condition  of  health.  They  are  usually  amenable  to  antispecific 
treatment. 

Pathology. — The  essential  lesion  consists  of  the  deposition  in  the 
submucosa  of  gumma  or  of  gummatous  tissue  either  in  a  circumscribed 
or  in  a  diflfuse  form.  Giant  cells  with  peripheral  position  of  the  nuclei 
(Langhans  type  of  giant  cells)  may  be  found  throughout  the  diseased 
tissue.  Such  an  infiltration  may  extend  secondarily  to  involve  the 
mucus  or  the  outer  layers  of  the  stomach  wall.  Surrounding  the 
gumma  is  found  a  zone  of  granulation  or  fibrous  tissue  depending  on 
the  age  of  the  lesion,  which  may  be  regarded  as  due  to  reparative 
reaction  of  the  adjacent  tissues.  In  other  cases  the  gumma  shows  a 
gradual  gradation  into  normal  gastric  tissue  and  has  no  fixed  line  of 
demarcation.  Gummas  are  apt  to  become  necrotic  in  the  centre  and 
may  rupture  through  the  surface.  In  the  gumma  there  almost  regularly 
occur  concentric  deposits  of  gummatous  tissue  around  and  in  the  walls 
of  the  small  bloodvessels,  so  that  an  obliterative  form  of  endarteritis 


304  TVBERCVLOSIS  AND  SYPHILIS  OF   THE  STOMACH 

results,  which  by  diminishing  the  normal  blood  supply  still  further 
increases  the  tendency  to  necrosis.  In  other  instances  the  necrotic 
portion  may  become  absorbed  and  replaced  by  a  mass  of  cicatricial 
tissue.  In  other  cases  the  gummatous  deposit  does  not  undergo  necrosis, 
but  may  either  undergo  resolution  or  may  become  converted  into  a 
diffuse  mass  of  fibrous  tissue.  The  absence  of  the  spirochete  is  not  to 
be  considered  an  evidence  against  the  specific  nature  of  the  affection. 
Syphilis  of  the  stomach  occurs  in  four  principal  forms: 

1.  Syphilitic  ulcer. 

2.  Syphilitic  tumor. 

3.  Syphilitic  pyloric  stenosis. 

4.  Syphilitic  cirrhosis. 

In  all  these  forms,  and  occasionally  in  syphilitic  patients  who  do 
not  present  one  of  the  above-mentioned  types  of  lesion,  we  are  apt 
to  have  a  well-marked  catarrhal  gastritis,  evidently  due  to  the  effect 
of  syphilitic  toxins. 

Secondary  and  associated  lesions  are  often  foinid  in  other  parts  of  the 
body.  Syphilitic  tumors,  ulcers,  and  stenosis  may  be  found  in  the 
jejunum,  sigmoid,  and  rectum,  and  in  the  esophagus.  Gummas  are 
often  found  in  the  liver,  occasionally  attaining  considerable  size.  Their 
favorite  seat  appears  to  be  in  the  left  lobe  or  in  the  neighborhood  of 
the  suspensory  ligament,  at  a  point  where  the  liver  undergoes  a  certain 
degree  of  traumatism  by  traction  of  the  ligament  at  this  point. 

Syphilitic  Ulcer. — Syphilitic  ulcers  may  be  either  solitary  or  mul- 
tiple, and  occur  in  any  part  of  the  stomach,  although  they  are  somewhat 
more  frequent  in  the  region  of  the  pylorus  and  lesser  curvature.  They 
vary  very  considerably  in  size  and  may  attain  considerable  proportions. 
The  ulcers  may  be  superficial,  extending  only  partially  through  the 
mucosa,  or  they  present  a  deep  excavated  appearance,  often  having 
a  serpiginous  outline.  Syphilitic  ulcers  are  regularly  the  result  of  the 
breaking  down  of  gummatous  tissue,  which  has  either  become  necrotic 
or  which  has  become  devitalized  by  reason  of  the  diminished  blood 
supply  through  the  partially  obliterated  bloodvessels  and  has  under- 
gone erosion  by  the  peptic  power  of  the  gastric  juice. 

Should  specific  endarteritis  occur  with  but  scanty  submucous  deposits 
of  gummatous  tissue,  pei)tic  erosion  may  occur  of  the  area  rendered 
thus  anemic  from  lack  of  sufficient  blood  supply  to  resist  the  corrosive 
action  of  the  gastric  juice.  An  ulcer  formed  in  this  way  does  not  present 
the  usual  appearance  of  syphilitic  ulcer,  as  its  walls  and  base  are  not 
former!  of  necrosing  gummatous  tissue,  but  may  })e  quite  indistinguish- 
able from  the  ordinary  form  of  gastric  ulcer,  although  microscopical 
examination  nia\'  show  the  characteristic  of  syphilitic  cndartiTitis  so 
that  there  is  no  doubt  of  the  specific  origin  of  the  ulcer. 


SYl'IIILIS  OF   THE  STOMACH 


305 


Symptoms. — The  symptoms  of  syphilitic  ulcer  (hj  not  vary  materially 
from  those  of  the  non-specifie  form.  Hemorrhage  or  perforation  may 
occur  and  either  complication  may  be  the  first  indication  of  the  gastric 
disease. 

In  one  of  the  writer's  patients,  a  young  man  was  taken  in  the  street 
with  such  severe  hematemesis  that  he  was  brought  by  ambulance 
into  the  hospital  in  an  exsanguinated  condition,  and  utterly  unable, 
by  reason  of  his  weakness,  to  give  any  facts  of  his  past  history.  The 
hemorrhages  continued  in  spite  of  all  treatment  and  he  died  eight 
hours  after  his  admission. 


Fig.  52 


Syphilitic  ulcer  of  the  stomach.     The  history  of  this  case  is  given  in  full  in  the  text. 


The  mucous  membrane  of  the  lesser  curvature  was  the  seat  of  an 
extensive  serpiginous  ulceration  involving  an  area  approximately 
6  by  5  cm.  The  edges  were  irregularly  sinuous,  slightly  raised  but  not 
indurated.  The  floor  was  composed  of  the  submucosa,  was  clean  and 
not  covered  by  slough.  About  2  cm.  from  the  left  border  of  the  cardiac 
orifice  just  within  the  margin  of  the  ulcer  were  seen  the  eroded  ends  of 
two  vessels  which  projected  slightly  above  the  surface  of  the  ulcer. 
About  3  cm.  from  the  pyloric  ring  along  the  greater  curvature  is  a  small 
polypoid  outgrowth,  adjacent  to  which  was  a  superficial  irregular  ulcer 
2  cm.  in  diameter  haA'ing  the  general  characteristic  of  the  larger  one 
just  described. 

The  wall  of  the  stomach  from  the  pyloric  ring  to  beyond  the  limits 
of  the  ulcer  was  markedly  thickened  by  the  replacement  of  tlie  sub- 
20 


3()(i  rVBERCULOSlS  AND  SYPHILIS  OF   THE  STOMACH 

mucosa  by  firm,  whitish,  infiltrating  tissue.  There  were  multiple 
gummas  in  the  liver.  The  mesenteric  lymph  nodes  show^ed  circular 
areas  of  firm  whitish  tissue,  A  detailed  account  of  the  microscopical 
findings  can  be  found  in  Pappenheimer's'  report  of  the  case. 

Diagnosis. — The  diagnosis  of  syphilitic  ulcer  cannot  be  made  on  the 
evidence  only  of  the  gastric  symptoms  presented,  but  it  is  to  be  surmised 
when  the  symptoms  of  ulceration  of  the  stomach  are  complained  of 
by  a  luetic  patient  who  has  obtained  no  relief  by  the  ordinary  forms 
of  treatment  for  his  ulcer.  This  suspicion  is  strengthened  to  the 
point  almost  of  certainty  should  rapid  and  lasting  recovery  follow  an 
antisyphilitic  course  of  treatment. 

Syphilitic  Tumors. — Every  gumma  is  a  tumor,  but  the  term  tumor 
is  clinically  applied  only  to  those  cases  in  which  the  growth  is  of  suffi- 
cient size  to  be  detected  by  palpation.  Ordinarily  gummas  are  not 
large  enough  to  be  easily  detected,  but  there  are  cases  in  which  they 
attain  the  size  of  an  egg,  or  even  larger  than  this,  and  may  be  easily 
detected  by  physical  examination.  They  may  be  single  or  multiple, 
occurring  in  parts  of  the  body  other  than  that  of  the  pylorus.  They 
give  no  characteristic  symptoms.  Pain  in  the  stomach  after  eating, 
with  occasional  vomiting,  may  be  complained  of,  together  with  con- 
siderable loss  of  flesh  and  strength;  but  these  are  the  symptoms  common 
to  a  great  number  of  gastric  disorders,  and  are  not  in  themselves  of 
diagnostic  value.  A  firm  nodular  resistance  is,  however,  felt  over  some 
portion  of  the  stomach;  which  may  so  closely  resemble  cancer  that  a 
differential  diagnosis  is  absolutely  impossible.  In  one  of  Einhorn's- 
cases  the  tumor  was  of  the  size  of  a  goose  egg. 

The  difficulty  in  making  a  diagnosis  between  syphilitic  tumor  and 
cancer  is  further  increased  by  similarity  in  the  gastric  analysis,  for  in 
the  majority  of  syphilitic  tumors  of  the  stomach  hydrochloric  acid, 
both  free  and  combined,  is  absent,  and  lactic  acid  may  be  present  in 
small  amounts. 

This  was  the  gastric  analysis  found  in  the  cases  reported  by  Curtis,'' 
but  it  is  not  the  invariable  rule,  for  in  one  case  reported  by  Einhorn,^ 
lactic  acid  was  not  present,  although  hydrochloric  acid  was  absent, 
while  in  a  second  case  by  Einhorn,-^  the  total  acidity  was  40  and  free 
hydrochloric  acid  was  present. 

The  diagnosis  is  to  be  suspected  in  every  case  of  tumor  of  the  stomach 

'  Medical  and  Surgical  Report  of  Hp11(>vuo  and  Allied  Hospitals,  1905-0,  ii,  219. 
2  Philadelphia  Med.  Jour.,  February  3,   1900,  p.  l.'()4. 
•^  Jour.  Amer.  Med.  Assoc,  April  10,  1909. 
^  Philadelphia  Med.  Jour.,  February  3,  1900. 
5  Dcrmatologische  Zeitsch.,   1900.  p.  450. 


SYPHILIS  OF   THE  STOMACH  '.'Ml 

that  occurs  in  syj)hilitic  siil)jects,  especially  if  other  e\i(l(>iices  of  the 
luetic  poison  such  as  gummas  of  the  liver  or  lesions  in  the  bones  can 
be  detected. 

Syphilitic  Pyloric  Stenosis. — Stenosis  of  the  pylorus  in  constitutional 
syphilis  may  occur  in  a  variety  of  ways.  There  may  be  a  thickening 
of  the  wall  of  the  pyloric  canal,  either  by  gumma  or  by  dense  fibrous 
tissue,  which  represents  one  of  the  end  results  f)f  the  syphilitic  infiltra- 
tion. In  other  cases  the  healing  of  an  ulcer  in  this  situation  may  be 
followed  by  a  cicatricial  contraction  of  the  orifice.  The  symptoms 
of  pyloric  stenosis  thus  induced  do  not  differ  from  those  of  pyloric 
stenosis  in  general. 

The  fasting  stomach  contains  residual  food,  indicative  of  a  grave 
motor  error.  Gastric  analysis  has  not  been  made  in  a  sufficient  number 
of  cases  to  enable  us  to  formulate  any  opinion  upon  its  value  as  a  diag- 
nostic aid. 

In  two  cases  reported  by  Einhorn  the  total  acidity  was  high  and  free 
hydrochloric  acid  was  present.  The  differential  diagnosis  cannot  be 
positively  made  from  benign  stenosis  or  from  cancerous  tumor  of  the 
pylorus. 

Cirrhosis  of  the  Stomach  of  Syphilitic  Origin. — It  is  not  uncommon 
that  gummatous  infiltration  shows  a  tendency  to  pass  into  a  condition 
of  fibroid  induration  which  may  be  localized  in  the  neighborhood 
of  the  pylorus  leading  to  pyloric  stenosis,  or  which  may  be  diffuse 
throughout  the  stomach  wall,  so  that  the  stomach  becomes  contracted, 
its  walls  thickened  and  fibrous,  the  appearance  being  apparently 
identical  with  that  of  the  non-specific  form  of  cirrhosis  of  the  stomach, 
so  that  a  differentiation  between  them,  save  by  most  careful  micro- 
scopical search,  cannot  be  made. 

Such  a  case  was  reported  by  Hemmeter  and  Stokes,^  The  patient 
was  a  young  man,  aged  twenty-four  years,  who  gave  the  history  that 
two  years  previously  he  had  contracted  syphilis.  Gastric  analysis 
showed  absence  of  hydrochloric  acid.  The  stomach  was  appreciably 
diminished  in  size.  Death  occurred  after  operation  for  the  relief  of 
pyloric  stenosis.  Autopsy  showed  the  stomach  wall  thickened,  especially 
in  the  region  of  the  pylorus,  where  the  opening  would  barely  admit 
a  lead-pencil.  A  number  of  cases  have  been  reported  of  this  form  of 
syphilitic  fibrosis  in  which  operations  were  done  for  pyloric  stenosis. 

It  does  not  seem  possible  that  a  difterential  diagnosis  can  be  made 
clinically  between  benign  fibrosis  of  the  stomach  (the  so-called  cirrhosis 
ventriculi),  fibroid  cancer  of  the  stomach  wall,  and  this  form  of  syphilitic 
fibrosis. 

'  Arch.  f.  \'erflauungskrank.,  1901,  \i\. 


;j()s        rrBERcuLosis  axd  sypiulis  of  the  stomach 

Treatment. — The  treatment  of  gastric  syphilis  is  that  onHnarily 
employed  in  tertiary  lesions.  A  thorough  course  of  iodide  and  mercury 
is  indicated  and  should  be  continued  so  long  as  any  improvement 
follows  the  treatment.  Injections  of  salvarsan  may  also  be  given  if 
the  diagnosis  is  established.  A  case  of  diffuse  syphilitic  infiltration 
from  the  stomach  of  cirrhotic  type  is  reported  by  Hausmann'  as  having 
been  cured  by  an  injection  of  salvarsan. 

F'ibroid  induration  of  pyloric  ulceration  or  gummas  that  result  in 
permanent  stenosis  may  be  treated  surgically  by  exsection  or  gastro- 
jejunostomy. 

'  Mimch.  med.  Woch.,  1911,  Xo.  10,  p.  511. 


CHAPTER    X 
ATONY  OF  THE   STOMACH 

General  Considerations. — Normal  Tonicity  of  Stomach. — Atony  of 
the  stomach  is  the  condition  in  which  the  stomach  wall  has  lost  its 
tonicity.  A  few  words  of  explanation  of  what  is  meant  by  tonicity 
may  be  necessary.  Three  forms  of  muscular  contraction  are  observed 
in  the  normal  stomach.  The  first  form  consists  in  a  concentric  drawing 
together  of  the  stomach  so  as  to  adapt  itself  to  the  volume  of  its  con- 
tents and  to  maintain  a  certain  uniform  pressure  upon  them.  This 
concentric  contraction  of  the  stomach  on  its  contents  is  often  spoken 
of  as  the  perisystole  of  the  organ,  and  the  diminution  of  this  motor 
function  results  in  what  we  term  "atony."  Tonus  is  essentially  the 
function  of  the  central  portion  and  fundus  of  the  stomach.  The  second 
form  of  muscular  contraction  is  a  vermicular  series  of  constricting 
rings  running  in  the  direction  of  the  longitudinal  axis  from  left  to  right. 
This  is  called  peristalsis  and  its  object  is  to  propel  the  contents  of  the 
stomach  from  the  fundus  toward  the  pylorus.  Peristalsis  is  especially 
the  function  of  the  prepyloric  portion  of  the  stomach.  These  two  motor 
functions,  tonus  and  peristalsis,  while  distinct  from  each  other,  are  to 
a  certain  extent  correlated  so  that  both  may  be  affected  at  the  same 
time,  although  one  may  be  impaired  and  not  the  other. 

The  third  form  of  motor  activity  of  the  stomach  is  shown  by  the 
alternate  contraction  and  relaxation  of  the  pyloric  sphincter  regulating 
the  outgo  of  food.  The  pylorus  remains  tonically  closed  even  against 
recurring  pressure  when  food  is  taken.  The  appearance  of  acid  at 
the  pylorus  causes  the  sphincter  to  relax  so  that  peristalsis  is  able  to 
expel  some  of  the  acid  chyme  into  the  duodenum.  The  acid  in  the 
duodenum  at  once  closes  the  sphincter  until  the  acid  has  been  more  or 
less  completely  neutralized  by  the  duodenal  secretions.  As  neutraliza- 
tion proceeds  the  duodenal  stimulus  causing  the  closure  of  the  pylorus 
becomes  weakened  so  that  the  acid  in  the  stomach  side  of  the  sphincter 
is  again  able  to  produce  relaxation  and  allow  of  the  expulsion  of  more 
chyme.  Beside  this  acid  control  of  the  sphincter,  the  pylorus  exerts 
a  selective  control  over  what  food  particles  may  be  allowed  to  pass — 
coarse  food  in  large  lumps  is  regularly  retained  in  the  stomach  longer 
than  digestible  food  finely  comminuted. 

When  food  enters  the  normal  stomach  it  does  not  drop  into  the  most 
dependent  portion  as  one  would  expect,  but  forms  a  column  of  about 


810 


ATOXV  OF   THE  STOMACH 


two-thirds  the  height  of  the  stoinacli.  As  more  and  more  food  is  added 
the  width  of  this  cohiniii  increases,  hut  not  the  heiglit,  the  upper  Hmit 
being  maintained  whether  the  volume  be  40  cc.  or  400  c.c.  The  reason 
for  this  is  tliat  the  normal  tonicity  of  the  stomach  wall  exerts  a  con- 
centric pressure  on  the  contents,  holding  them  in  a  tubular  form.  The 
greater  curvature  is  but  little  depressed  as  the  stomach  is  gradually 
filled.  Above  the  column  of  food  is  an  air  chamber  which  is  quite 
constant. 

When  atony  is  present  this  close  adaptation  of  the  stomach  to  its 
contents  no  longer  occurs,  but  food  drops  into  the  most  dependent 
portion  of  the  stomach,  lying  there  more  or  less  transversely  and  sagging 
the  stomach  downward,  so  that  the  lower  curvature  may  be  1  or  2 
inches  below  the  umbilicus.  As  more  food  is  taken  the  greater  curvature 
sinks  more  and  more  deeply,  while  the  upper  limit  of  the  contents  rises 
only  to  a  slight  extent.  The  air  space  is  much  larger  than  normal  and 
assumes  roughly  a  cylindrical  form  with  a  bulbous  upper  extremity. 

The  difference  in  the  filling  of  the  normal  and  atonic  stomachs  may 
be  shown  by  the  accompanying  diagrams. 


Fig.  53 


Filling  of  the  norma!  stomach,      f,  unibilii'us;  L.  upper  limit  of  gastric  contents.      (Hertz.) 


Fia.  54 


Filling  of  the  atonic  stomach,      i',  umbilicus;  L,  upper  limit  of  gastric  contents.      (Hertz.) 


PLATE    Vlir 


Fig.    1 


Filling  of  the  Normal  Stomach.       (Radiologist,   Dr.   Cole.) 


Fig.  2 


Filling  of  the  Atonic  Ston-iach.      (Radiologist,   Dr.   Learning.) 


(HiN ERA  L   ( 'ONSIDI'JRA  TfOXS  3 1 1 

Every  atony  is,  in  its  inception,  a  lack  of  toinis  aflVctint;-  chiefly  the 
fundus  i)()rtion  of  the  stomach.  When  thus  hniited  the  peristaltic 
function  nia\'  he  quite  unimpaired,  so  that  the  stomach  will  empty 
itself  within  ])roper  time  limits.  In  these  eases  examination  by  means 
of  test  meals  may  not  reveal  the  least  retardation  in  the  expulsion  of 
food  from  the  stomach,  although  well-marked  atony  may  be  demon- 
strated by  the  .r-ray. 

When  the  process  becomes  more  marked  and  more  generalized, 
the  peristaltic  function  becomes  impaired  with  a  resulting  tardiness 
in  the  onward  propulsion  of  food  into  the  duodenum.  This  delayed 
exit  of  food  may  be  clearly  shown  by  the  presence  of  test  meals  in  the 
stomach  after  they  should  have  been  expelled,  but  although  normal 
time  limits  may  have  been  passed,  the  error  is  never  so  grave  as  to 
lead  to  what  we  might  call  food-stasis.  The  onward  current  may 
be  slow,  but  it  is  certain.  The  stomach  is  regularly  and  invariably 
empty  in  the  morning  fasting  state  in  uncomplicated  cases  of  atony. 
This  test  alone  differentiates  distinctly  between  atony  and  pyloric 
stenosis. 

Occurrence. — Atony  is  one  of  the  commonest  causes  for  dyspepsia 
and  occurs  in  the  writer's  experience  in  one  of  every  seven  patients  in 
private  practice  complaining  of  their  digestion.  In  hospital  cases  the 
ailment  is  probably  less  than  half  as  frequent. 

Sex. — There  seems  to  be  no  greater  liability  to  the  affection  in  women 
than  in  men,  although  reasoning  from  the  etiology  of  the  disease  women 
would  seem  to  be  peculiarly  predisposed  to  the  ailment.  In  the  writer's 
cases  39  per  cent,  were  observed  in  men  and  61  per  cent,  in  women, 
but  the  number  of  women  applying  for  treatment  w^as  just  about  in 
this  proportion,  so  that  the  difference  in  frequency  in  the  two  sexes 
is  not  as  great  as  it  really  would  appear  to  be. 

Age. — The  functional  disorder  is  rare  in  childhood,  but  occurs  evenly 
distributed  through  the  adult  life  if  we  class  men  and  women  together. 
In  both  men  and  women  atony  occurred: 

Between  10  and  20  years 6  per  cent. 

Between  20  and  30  years 29  per  cent. 

Between  30  and  40  years 26  per  cent. 

Between  40  and  50  years 26  per  cent. 

Between  50  and  60  years 12  per  cent. 

Between  60  and  70  years 1  per  cent. 

100  per  cent. 

When  we  separate  the  men  from  the  women  we  find  that  in  women 
the  disorder  occurs  at  a  far  earlier  period  of  life  than  in  men. 


312  ATONY  OF  THE  STOMACH 

111  100  cases  of  aton^•  in  women  there  occurred: 


Belwt'Pii  10  and  20  years 
Between  20  and  30  years 
Between  30  and  40  years 
Between  40  and  50  years 
Between  50  and  60  years 
Between  60  and  70  years 


10  cases 
38  cases 
23  cases 
18  cases 

11  cases 
0  cases 

100  cases 


Of  100  cases  of  atonv  in  mer 


Between  10  and  20  years 
Between  20  and  30  years 
Between  30  and  40  years 
Between  40  and  50  years 
Between  50  and  60  years 
Between  60  and  70  years 


there  occurred: 


0 

cases 

15 

cases 

30 

cases 

38 

cases 

15 

cases 

2 

cases 

100 

cases 

The  differences  in  the  ages  at  whicli   the  disorder  is  manifest    is 
shown  by  the  accompanying  table: 


Fig.  5o 

30.-I0  40..J0 


/\ 

^^- 

-             s 

/ 

y 

V/*" 
•'n^ 

\. 

\ 

/ 

y^ 

y" 
y 

^^- 

> 

y 
y 
^ 

^<v 

^v^ 

MEN 

WOMEIM- 


The  period  of  greatest  lial)ihty  in  men  to  gastric  atony  is  that  of  the 
gravest  responsibilities  of  life.  The  cause  for  tiie  earlier  appearance 
of  the  disorder  in  women  is  more  difficult  to  inidcrstand.  ]\Iany  of 
the  writer's  cases  occurred  in  nervous  delicate  women,  socially  active, 
living  on  their  nerves,  often  with  the  history  of  rapid  child-bearing 
and  frefiucnt  pelvic  operations. 

Etiology. — Atony  is  a  functional  disorder  due  to  lack  of  tonus  of  the 
stomach  wall  that  may  arise  from  general,  local,  or  from  reflex  causes. 

General  Causes. — Every  neurasthenic  is  predisposed  to  atony  by 
reason   of   his   nervous  condition.       Neurasthenia,   irrespective  of   its 


ETJ()I/)(!Y  313 

duration,  is  the  underlying  factor  that  iiuhices  the  gastric  disorder  in 
the  very  great  majority  of  instances.  The  nerNous  weakness  may  be 
congenital  or  acquired. 

In  25  per  cent,  of  the  writer's  cases  there  were  the  stigmas  of  the 
so-called  congenital  neurasthenia  described  b}'  Stiller,  the  outward 
signs  of  which  are  shown  by  what  is  termed  the  enteroptotic  habitus. 
The  costal  angle  is  sharp,  measuring  less  than  50°  to  55°;  the  margins 
of  the  ribs  pass  more  vertically  downward  than  in  normal  individuals. 
The  tenth  rib  is  frequently  unattached,  the  thorax  is  long  and  slender, 
the  intercostal  spaces  broad  and  sunken.  The  patient  is  almost  in- 
variably of  delicate  frame  and  of  spare  habit.  Visceral  ptoses  can 
be  easily  demonstrated.  In  these  patients  with  the  enteroptotic  habit 
gastro-intestinal  atony  is  an  inherent  part  of  a  general  constitutional 
weakness  and  is  liable  to  make  itself  manifest  by  symptoms  of  indiges- 
tion whenever  the  patient  runs  down  from  any  cause  whatever.  These 
are  the  patients  who  are  constitutionally  unable  to  withstand  the  storm 
and  stress  of  daily  life  and  who  habitually  have  indigestion  unless  life 
is  made  easy  for  them  in  every  possible  way;  This  constitutional 
anomaly  should  be  suspected  whenever  a  patient,  especially  if  thin 
and  undernourished,  complains  of  "having  a  delicate  stomach"  as 
long  as  he  can  remember. 

Acquired  neurathenic  or  psychasthenic  states  may  follow  any  variety 
of  nervous  or  physical  strain,  prolonged  or  temporary.  Transient 
atony  may  follow  sudden  physical  or  nervous  crisis,  such  as  operations, 
sudden  calamities,  acute  illness,  overfatigue,  sexual  excesses,  or  pro- 
longed lack  of  sleep.  The  removal  of  the  exciting  cause  may  be  followed 
by  a  more  or  less  rapid  restitution,  although  in  many  cases  atony 
induced  b.y  temporary  causes  may  continue  for  weeks  or  may  even 
become  permanent. 

Chronic  Exhausting  Diseases. — Atony  is  a  regular  accompaniment 
of  all  chronic  exhausting  diseases,  of  which  tuberculosis  and  diabetes 
furnish  perhaps  the  most  typical  examples.  The  excessive  quantities 
of  milk  or  of  water  taken  in  these  two  ailments  further  increase  the 
degree  of  the  atony. 

Almost  all  patients  with  chlorosis  show  atony  of  the  stomach  of  greater 
or  less  degree. 

Local  Causes. — The  local  causes  for  atony  are  not  so  numerous  as 
are  the  general  causes  for,  nervous  depreciation.  Excesses  of  eating  and 
drinking  may  be  followed  by  the  symptoms  of  the  ailment.  A  very 
frequent  cause  is  the  habit  of  drinking  water  to  excess,  especially  at 
meals,  mechanically  overloading  the  stomach  by  excessive  weight 
and  bulk  of  its  contents.  Physicians  should  be  more  careful  and  dis- 
criminating than  thev  are  in  advising  or  allowing  such  a  "water  cure." 


314  ATOXY   OF   THE  STOMACH 

Many  people  are  obsessed  with  the  idea  that  tlie  more  they  drink 
tlie  healthier  they  are,  and  in  conseciuence  fill  the  stomaeh  with  water 
at  the  rate  of  a  pound  a  i)int  at  every  possible  opportunity.  ^Yhen 
the  water  is  taken  ieed,  the  greater  is  the  damage  done. 

Excessive  quantities  of  food,  or  food  improperly  masticated,  contain- 
ing coarse  indigestible  lumps,  are  often  retained  in  the  stomach  for 
an  abnormal  period  of  time  through  a  selective  action  of  the  pylorus. 
This  is  a  well-known  cause  for  acute  indigestion,  and  occurs  freciuently 
enough  in  the  experience  of  everyone.  When  these  dietetic  errors  are 
constantly  repeated  gastric  atony  may  result,  although  cases  thus 
induced  are  less  frequently  encountered  than  one  would  be  led  to 
suppose.  Atony  is  relatively  less  common  in  hospital  and  dispensary 
patients  who  habitually  ill  treat  their  stomachs  than  in  private  patients 
who  are  careful  of  what  they  eat. 

Atony  is  a  common  sequel  to  any  form  of  acute  gastritis  and  often 
is  the  means  of  protracting  convalescence  long  after  the  acute  inflam- 
matory symptoms  have  subsided.  With  chronic  gastritis  atony  does 
not  appear  unless  due  to  other  causes  than  the  gastric  catarrh. 

Reflex  Causes. — Reflex  causes  for  atony  may  originate  from  irritative 
lesions  anywhere  within  the  abdominal  cavity.  Tumors  of  the  ovary 
or  spleen,  epigastric  hernia,  mesenteric  cysts,  and  renal  calculus  have  all 
been  proved  to  stand  in  a  casual  relationship  to  the  disorder.  Lesions 
of  the  gall-bladder  and  gallstones  are  the  most  frequent  of  these  causes. 
Acute  cholecystitis  is  frequently  accompanied  by  symptoms  of  gastric 
atony,  and  these  may  be  so  pronounced  as  to  overshadow  those  due  to 
the  gall-bladder  infection  and  to  thus  obscure  the  diagnosis. 

Appendicitis  does  not  seem  to  be  a  frequent  cause  for  atony,  imless 
the  appendicular  disease  occurs  in  a  patient  who  has  the  enteroptotic 
habit  and  visceral  ptosis.  In  such  a  subject  atony  during  chronic 
appendicitis  is  liable  to  occur. 

Irritative  lesions  of  the  pelvic  organs  in  both  sexes  are  commonly 
accompanied  by  atony,  and  should  always  be  suspected  in  obscure 
cases.  Ovarian  cysts  and  uterine  displacements  in  women,  chronic 
prostatitis,  and  seminal  vesiculitis  in  men  are  the  lesions  most  usually 
found. 

Whether  atony  of  the  stomach  may  result  from  irritative  conditions 
of  the  intestine  or  colon  is  not  as  yet  a  j)r()ved  fact,  although  probable 
from  experimental  and  clinical  observation.  Symptoms  of  atony 
complicated  by  extreme  degrees  of  constipation  are  often  relieved  by 
the  expulsion  of  old  fecal  masses,  by  laxatives  or  enemas.  Atony 
may  apparently  be  induced  by  the  continued  use  of  irritating  purga- 
tives, and  this  probably  is  a  frequent  cause  for  the  complaint  in  women. 
Cannon  injected  a  few  drops  of  croton  oil  into  the  cecum  of  cats  and 


HYMI'TOMS  315 

the  t'ollowiiifi;  (la\'  ivi\  tlicni  with  a  hisniiith  jxjtato  iiicaL  Xo  potato 
entered  the  colon  until  six  or  scxcn  hours  had  elapsed,  and  the  food  was 
still  present  in  the  stomach  at  tlie  end  of  seven  hours;  wliereas  under 
ordinary  conditions  potato  would  be  found  in  the  colon  within  two  or 
three  hours  and  the  stomach  would  be  empty  at  the  end  of  this 
time. 

Symptoms. — Of  all  the  symptoms  of  atony,  flatulence  is  the  one  of 
which  complaint  most  commonly  is  made.  Flatulence  may  be  either 
gastric,  intestinal,  or  both.  In  the  writer's  cases  gas  in  the  stomach 
constituted  the  chief  complain  in  77  per  cent.,  intestinal  distention 
alone  in  51  per  cent.,  while  in  but  12  per  cent,  distress  from  gas  w^s 
slight  or  absent.  Gastric  and  intestinal  discomfort  from  flatulence 
occurred  together  in  40  per  cent,  of  the  cases. 

Gastric  Flatulence. — Gastric  flatulence  produces  a  sense  of  fulness, 
distention  and  discomfort.  Actual  pain  from  gaseous  distention  is 
so  rarely  observed  that  its  occurrence  should  suggest  a  complicating 
pyloric  spasm.  The  distress  usually  begins  shortly  after  eating,  con- 
tinues for  an  hour  or  so,  and  gradually  subsides.  The  degree  of  distress 
is  dependent  more  upon  the  quantity  of  the  meal  than  upon  the  char- 
acter of  the  food  that  is  eaten.  The  larger  the  meal,  the  greater  is  the 
distress.  Water  may  cause  as  much  discomfort  as  an  equal  weight  of 
solid  food.  In  mild  cases  the  annoyance  may  be  apparent  only  after 
the  heartier  meals,  and  may  be  slight  or  absent  if  smaller  meals  are 
taken,  while  in  severer  cases  every  meal,  no  matter  how  scanty  its 
quantity,  may  be  followed  by  the  complaint.  In  the  most  advanced 
forms  of  atony,  even  small  quantities  of  water  may  provoke  the 
discomfort. 

In  mild  degrees  of  atony  there  is  a  period  of  relief  and  comfort  appear- 
ing two  to  four  hours  after  eating  and  lasting  until  the  next  meal  is 
taken,  but  in  severer  types  of  the  disorder,  distress  is  more  continuous 
and  the  discomfort  merges  into  that  caused  by  the  succeeding  meal, 
so  that  at  no  time  is  the  patient  really  comfortable.  The  gas  ma\'  be 
freely  raised  and  passed  or  the  patient  may  be  unable  thus  to  find 
relief,  the  gas  "stays  fixed."  It  not  infrequently  happens  that  dis- 
tention may  persist  during  the  greater  part  of  the  night,  preventing 
sleep  or  waking  the  patient  during  the  early  morning  hours.  The  degree 
of  flatulence  is  almost  invariably  increased  if  the  patient  be  overtired 
or  more  than  ordinarily  nervous.  In  many  cases  distress  only  occurs 
on  the  days  of  overstrenuous  living  and  excitement. 

The  tendency  of  the  patient  is  regularly  to  attribute  his  discomfort 
to  something  that  has  disagreed,  and  he  feels  that  this  is  so  because 
with  gaseous  eructations  he  can  "taste  his  food."  The  result  is  that 
he  cuts  off  one  article  after  the  other  until  he  is  reduced  to  a  starva- 


31(i  ATOXY  OF   THE  STOMACH 

tion  diet,  and  l)y  l)ec()miii<;-  weak  and  run  down  increases  his  atony 
to  such  an  extent  that  he  suii'ers  as  much  or  more  with  his  insufficient 
diet  as  he  did  when  he  ate  more  liherally.  Eructations  of  gas  bear- 
ing the  odor  of  food  that  has  been  eaten,  means  absohitely  nothing 
unless  the  repetition  of  taste  occurs  hours  after  the  ingestion  of  food  at 
a  time  when  the  stomach  should  normally  be  empty.  It  is  then  an 
indication  of  tardy  food  expulsion  rather  than  a  test  of  whether  the 
food  is  or  is  not  properly  digested.  Inflation  of  the  stomach  by  gas 
may  induce  nausea,  or  may  embarrass  the  action  of  the  heart  and  c-ause 
rapidity  f)f  the  i)ulse,  palpitation,  and  dyspnea. 

Intestinal  Distress. — Intestinal  distress  may  be  occasioned  by  the 
passage  of  gas  from  the  stomach  into  the  Ijowel  or  may  be  due  to  an 
associated  atony  of  the  intestinal  wall.  Abdominal  distention  usually 
appears  three  or  four  hours  after  the  meal,  occurring  one  or  two  hours 
later  than  the  distress  occasioned  by  the  gas  in  the  stomach,  and  is 
more  continuous,  so  that  it  becomes  an  annoying  feature  of  the  disease 
during  the  night.  Flatus  may  be  easily  passed,  or  the  gas  may  simply 
"roll  around." 

Heaviness  and  Sense  of  Weight. — Heaviness  and  sense  of  weight  in 
the  stomach  were  the  cause  for  complaint  in  42  per  cent,  of  the  writer's 
series.  The  patient  feels  that  he  has  ()\ereaten  even  though  the  meal 
be  light  and  is  inclined  to  sit  still,  as  the  upright  position  aggravates 
his  discomfort.  Lying  down  is  equally  distressing,  as  the  stomach  con- 
tents press  up  on  the  diaphragm  and  cause  dyspnea  and  palpitation. 
The  sense  of  heaviness  is  directly  ])r()])()rtionate  to  the  mechanical 
weight  of  what  has  been  taken  and  is  not  influenced  in  the  least  by  the 
character  of  the  food. 

Constipation. — The  l)owels  are  usually  constipated.  In  the  writer's 
series  constipation  was  noted  in  75  per  cent.,  attacks  of  diarrhea  alter- 
nating with  constipation  occurred  in  15  per  cent.,  while  in  10  per  cent. 
the  action  of  the  bowels  was  regular.  Constipation  if  present  is  almost 
regularly  due  to  a  concomitant  intestinal  atony,  often  aggravated 
l)y  an  insufficient  diet.  The  diarrheal  attacks  seem  to  be  caused  by 
recurring  irritation  from  intestinal  stasis  or  to  the  overuse  of  the 
cathartics  to  which  the  patient  becomes  addicted. 

Nausea. — Nausea  is  present  in  about  one-fifth  of  the  cases.  The 
nausea  is  rarely  extreme,  seldom  if  ever  j)assing  into  the  active  stage 
of  vomiting,  neither  does  it  seem  to  be  closely  dependent  upon  the 
taking  of  food,  but  more  usually  api)ears  at  any  time  -irrespective  of 
the  meals  and  comes  and  goes  throughout  the  day.  It  is  not  influenced, 
as  a  rule,  by  the  character  of  the  food.  Occasionally  nausea  appears  in 
sudden  sharp  attacks  relieved  entirely  by  eructations  of  wind  from  the 
stomach. 


DIAGNOSIS  y,\7 

Appetite. — 'riie  appcfik'  is  rarely  iionnul.  Tiic  patient  usually  is 
fairly  hungry  at  the  meal,  but  after  a  few  mouthfuls  "feels  stuffed," 
so  that  he  can  eat  no  more  with  comfort.  This  early  satiety  is  observed 
in  nearly  all  the  cases  of  atony.  Aversion  to  food  is  more  rare,  as  actual 
anorexia  occurred  in  only  5  per  cent,  of  the  writer's  series.  A  feeling 
of  being  "all  gone"  in  the  region  of  the  stomach  may  appear  two  or 
three  hours  after  the  meal.  The  patient  "would  gladly  eat  if  he  felt 
he  could."    This  occasioned  complaint  in  5  per  cent,  of  the  series. 

Vomiting. — Vomiting  is  but  rarely  observed,  except  as  a  symptom 
of  "sick  headache,"  although  some  of  the  neurasthenic  patients  may 
contract  the  habit  of  inducing  vomiting  to  dislodge  the  gas.  The 
vomited  matters  never  contain  traces  of  residual  food  of  ancient  date 
as  in  pyloric  stenosis. 

Heart-burn. — Heart-burn  may  be  observed  in  a  few  instances,  occur- 
ring in  the  writer's  series  in  but  4  per  cent.  Many  patients  bring  up  gas 
and  with  it  a  few  particles  of  digesting  food  naturally  and  normally 
acid,  and  say  that  they  have  acidity  and  sour  stomach.  Their  mis- 
apprehension on  this  point  is  obvious. 

Headache. — Symptoms  which  we  ordinarily  ascribe  to  avto-infoxica- 
tion  are  common  with  gastric  atony,  or  more  usually  with  a  combination 
of  gastric  and  intestinal  atony. 

Of  these,  headache- constitutes  the  most  common  complaint  and 
occurred  in  all  of  the  writer's  cases.  The  most  common  form  is  the 
so-called  "sick  headache"  or  "bilious  headache,"  occurring  periodic- 
ally. Beginning  usually  over  one  or  the  other  eye  the  pain  becomes 
hemicranial  in  distribution,  and  is  attended  by  nausea  and  vomiting. 
Scotomas  and  other  visual  symptoms  are  usually  absent.  In  other 
instances,  the  headache  is  dull  and  occipital,  usualh^  more  intense 
on  awakening  and  passing  off  gradually  as  the  day  progresses. 

Dizziness  is  not  uncommon,  usually  being  characterized  by  its  con- 
stancy rather  than  by  its  severity. 

Many  writers  speak  of  morbid  apprehensions  and  fears  as  charac- 
teristic of  gastric  atony.  This  has  not  been  the  writer's  experience,  as 
in  but  2  per  cent,  of  his  series  was  there  any  mention  of  any  form  of 
phobia.  It  would  seem  more  probable  that  the  morbid  fears  were 
due  to  the  original  psychasthenic  state  rather  than  to  the  atony  that 
occurred  in  such  a  neurotic  subject. 

Diagnosis.-  -Physical  Signs. — x\tony  may  be  present  without  an\' 
physical  signs  to  re\eal  its  ])resence,  so  that  negative  results  on  examina- 
tion should  not  throw  out  the  diagnosis.  Rei)eated  examinations  are 
often  necessary,  as  the  condition  may  be  more  e\Mdent  at  some  time 
than  at  others.  The  physical  signs  are  usually  more  evident  two  or 
three  hours  after  eating  than  at  an\"  other  tiin'j. 


3  IS 


-17YJ.V}'  OF   THE  STOMACH 


1.  Much  valuable  evidence  may  be  aft'orded  by  the  physical  inspec- 
tion of  the  patient.  Stout,  healthy  looking  indi\iduals  with  broad 
costal  angles  are  rarely  subject  to  functional  disorders  of  digestion  and 
in  such  subjects  atony  is  comparatively  rare.  Those  who  are  delicately 
built,  of  highly  sensitive  nervous  organizations,  and  who  are  thin  and 
peaked,  are  more  liable  to  the  disorder,  and  especially  is  this  the 
case  with  those  whose  costal  angle  is  sharp  and  who  present  the  other 
stigmas  of  the  enteroptotic  habitus.  Gastroptosis  is  the  strongest 
presumable  j)roof  of  atony,  and  occurred  in  over  one-third  of  the 
writer's  cases  of  the  ailment. 


Fig.  56 


Writer's  gastrodiaphane. 


2.  An  atonic  stomach  may  not  necessarily  })e  a  large  stomach  at  all 
times,  but  it  is  a  stomach  that  is  abnormally  distensible  and  lacking 
tone,  tends  to  sag  deeper  and  deeper  as  more  food  is  put  into  it.  Ex- 
amination of  the  patient  as  he  lies  down  may  show  that  the  greater 
curvature  lies  at  or  ab()^•c  the  umbilicus,  especially  if  the  organ  be  com- 
paratively empty.  When  he  stands,  however,  and  several  glasses  of 
water  are  taken,  the  lower  cur\ature  sags  so  as  to  reach  2  or  more  inches 
below  the  umbilicus.  This  is  more  clearly  shown  by  .r-ray  examination 
than  by  the  other  means,  for  it  is  often  very  difficult  to  locate  the  lower 
curvature  in  the  standing  i)<)sture.  (lastr()diaj)hany  or  the  introduction 
of  small  electric  lights  into  the  stomach,  so  that  they  lie  in  the  most 
depeiident  portion  of  the  organ,  would  api)arentl\'  be  of  service,  as  it 
would  seem  that  the  lower  curvature  of  the  stomach  could  be  located 
i)y  tlic  point  of  inaximuni  intensity  of  the  transmitted  illumination. 
The  writer  lias  been  guilty  of  ha\'ing  dcxiscd  a  gastro(liai)hanc,  but  has 


DIAdXOSIS  319 

long  since  atjandoncd  its  use  as  ht-infi;  utterly  niitrustworthy  for  any 
purpose  whatever, 

JModerate  inflation  of  the  stomach  is  perliai)s  the  most  accurate  means 
of  locating  its  lower  border,  hut  it  must  be  })orne  in  mind  that  the  stomach 
is  so  distensible  that  the  more  it  is  inflated  the  larger  it  becomes,  so 
that  entirely  erroneous  results  may  be  obtained.  Meinert  made  this 
error  when  he  aimounced  that  almost  all  chlorotic  girls  had  dilated 
stomachs.  He  simply  overdilaterl  distensible  atonic  stomachs  that 
may  not  have  been  larger  than  normal  if  he  had  let  them  alone.  In- 
flation in  atony  should  be  only  to  the  extent  of  producing  a  change  of 
note  in  the  auscultatory  percussion  of  the  organ.  Inflation  greater 
than  this  is  unnecessary,  misleading,  and  unjustifiable. 

3.  Splashing  sounds  by  percussion  or  palpation  of  the  stomach  are 
readily  elicited  in  atony  and  may  or  may  not  be  of  diagnostic  signifi- 
cance. Almost  any  normal  stomach  will  produce  percussion  sounds 
when  it  is  violently  agitated  at  a  time  when  it  is  full.  In  very  thin 
subjects  succussion  sounds  may  be  normally  produced  by  deep  palpa- 
tion. With  atony  these  so-called  deep  succussion  sounds  are  of  no 
diagnostic  significance.  Succussion  sound  produced  by  light  palpation 
may  be  heard  normally  in  women  whose  abdominal  wall  is  greatly 
relaxed  as  the  result  of  repeated  child-bearing,  but  otherwise  occurring 
in  a  patient  whose  abdominal  wall  offers  an  apparent  normal  resistance 
to  palpation,  succussion  sounds  that  are  audible  by  the  slightest 
tapotement  aflFord  presumptive  proof  of  atony.  Succussion  sounds 
in  atony  cannot  be  demonstrated  when  the  stomach  should  be  empty, 
but  if  after  fasting  they  reappear  after  the  ingestion  of  a  half-glass  of 
water,  atony  may  be  diagnosticated  almost  with  certainty. 

4.  In  atony  visible  peristalsis  is  never  evident  nor  can  gastric 
stiflFening  ever  be  demonstrated 

Radiographic  Diagnosis. — The  radiographic  diagnosis  of  atony  is 
based  on  the  examination  of  two  sets  of  plates,  one  taken  six  hours 
after  the  bismuth  meal,  the  other  directly  after  the  stomach  has  been 
filled  with  the  bismuth  suspension  after  the  six-hour  plate  has  been 
taken. 

Bismuth  residue  in  the  stomach  six  hours  after  the  first  bismuth 
meal  may  be  due  to  pyloric  stenosis,  to  ulcer  of  the  lesser  curvature, 
to  cancer,  to  perigastric  adhesions  limiting  free  motility,  or  to  atony. 
Large  semilunar  residues  extending  far  to  the  right,  may  obviously 
be  due  to  pyloric  stenosis,  but  otherwise  the  ditt'erential  diagnosis 
between  these  conditions  cannot  be  made  by  the  study  of  the  six-hour 
plate  above.  The  general  outlines  of  the  bismuth  residue  in  the  six- 
hour  plates  are  shown  diagrammatically  by  Holzknecht. 

It  must  be  remembered,  however,  that  atony,  to  a  clinical  degree, 


320 


ATOiW  OF   THE  STOMACH 


may  exist  with  normal  food  expulsion — the  lack  of  tonus  not  being 
accompanied  by  any  corresponding  lack  of  peristalsis.  In  such  instances, 
the  six-hour  plate  may  show  no  bismuth  residue  whatever,  so  that  a 
negative  plate  does  not  exclude  atony. 


Fig.  .i7 


^J 


Residue  after  six  hours.  The  position  of  the  residue  is  shown  in  relation  to  the  umbilicus: 
.1,  small  residue  due  to  atony,  spasm  of  the  pylorus,  or  shght  stenosis;  B,  broad  extensive  residue, 
due  to  uncomplicated  stenosis  of  the  pylorus;  noteworthy  arc  the  bowl-shape  of  the  residue  and  its 
extension  far  to  the  right  of  the  median  line;  C,  "snail  form,"  from  shrinkage  of  the  lesser  curva- 
ture due  to  ulcer,  residue  far  to  the  lolt  with  sharp  bend  of  the  greater  curvature;  D,  residue  dis- 
placed to  the  left,  margin  well  defined  and  jagged,  no  displacement  of  pylorus,  tumor  of  the  pylorus. 
(Drawn  from  Handek,  in  Holzknecht's  article  in  Archives  in  Rontgen  Rays,  July,  1912,  p.  69.) 


The  second  bismuth  suspension  meal  given  after  the  six-hour  plate 
has  been  taken  serves  to  show  the  outline  of  the  filled  stomach.  The 
different  ajjpearances  of  the  filled  stomach  are  shown  in  the  accompany- 
ing diagram  from  Ilolzknecht. 

"This  classification,''  writes  Ilolzknecht,  "according  to  the  habitual 
tone  of  the  organ  gix'es  us  a  method  of  testing  the  motility  of  the  stomach 
far  in  advance  of  anything  obtainable  by  the  ordinary  clinical  methods. 
As  may  be  seen  in  the  diagrams  the  normal  time  for  the  complete  evac- 
uation of  the  stomach  varies  between  two  and  eight  hours.  For  types 
3  and  4  a  delay  of  six  hours  would  be  normal,  whereas  for  type  1  it 
would  indicate  some  obstruction  in  the  pylorus.  In  type  4  even  eight 
hours'   delay  would    lead    us   to   no   susi)icion   of   either  spasmodic   or 


DIAGNOSIS  321 

permanent  contraction."     In  general  Ilolzkncclit  is  correct  in  tlie  al)ove 
conclusions. 

It  can  hardly  be  said,  however,  that  the  hypotonic  and  atonic  types 
can  be  included  among  those  of  the  normal  stomach.  An  atonic 
stoma<?h  is  certainly  not  a  normal  organ.  Neither  must  it  be  assumed 
in  every  instance  of  these  atonic  types  that  food  evacuation  is  delayed, 
for  as  has  been  previously  explained,  lack  of  tonus,  or  atony,  may  or 
may  not  be  associated  with  a  corresponding  reduction  in  peristalsis. 

Fig.  58 
Orthotonic 

■J  to  J  It  IS. 


Ordinary  forms  of  the  full  stomach  due  to  differences  in  tone,  patient  standing.     The  figures 
indicate   in   each   case   the   time   required   for   complete   evacuation. 

In  atony  the  bismuth  meal  falls  quickly  to  the  most  dependent  por- 
tion of  the  stomach,  lying  transversely,  and  sagging  the  organ  down- 
ward, leaving  the  upper  portion  empty  except  where  the  rugse  have 
retained  the  bismuth.  The  walls  of  the  pars  media  are  seen  quite 
collapsed,  appearing  as  a  vertical  cord.  The  lower  portion  of  the  stomach 
is  Avell  distended  and  displaced  downward,  lying  well  below  the 
umbilicus  in  the  upright  position  of  the  patient.  The  p}dorus,  however, 
will  be  at  its  normal  point  and  the  terminal  portion  of  the  greater  curva- 
ture will  sweep  upward  and  to  the  right.  The  stomach  bubble  is  usually 
of  large  size,  although  the  bubble  may  be  exceedingly  small. 

The  shape  of  the  stomach  differs  materially  from  the  "snail  form" 
of  ulcer  or  cancer  of  the  lesser  curvature,  and  from  the  "undershot" 
appearance  of  the  greater  curvature  as  seen  in  pyloric  stenosis. 

The  outline  in  atony  is  not  irregular,  nor  indented,  as  with  ulcer, 
cancer,  or  extensive  adhesions.  The  differences  between  the  appearance 
of  the  filling  of  the  normal  stomach  and  that  with  atony  have  been 
previously  described. 

Gastric  Analysis, — The  ordinary  routine  examination  of  the  fasting 
stomach  and  test  breakfast  may  afford  but  scanty  proof  of  the  existence 
21 


322  ATONY  OF  THE  STOMACH 

of  atony,  although  it  is  serviceable  in  excluding  other  disorders.  A 
third  test  has  to  be  added  which  concerns  itself  in  the  length  of  time 
the  food  is  retained  in  the  stomach  before  it  passes  on  its  way.  We 
have,  therefore,  to  consider  the  fasting  stomach,  the  test  breakfast, 
and  tests  for  motility. 

Fasting  Stomach. — The  fasting  stomach  in  atony  should  in^^ariably 
be  empty.  Demonstrable  food  remains  or  hypersecretion  are  never 
encountered  in  simple  functional  atony,  and  the  atonic  dilatation  of 
the  stomach  described  by  older  writers  does  not  exist. 

It  is  unfortunate  that  many  writers  speak  of  atony  as  muscular 
insufficiency  of  the  first  degree,  and  of  pyloric  stenosis  as  muscular 
insufficiency  of  the  second  degree,  as  if  the  former  might  merge  into 
the  second.  Atony  and  pyloric  stenosis  are  two  distinct  conditions, 
having  no  relationship  whatever  with  each  other.  In  pyloric  stenosis 
the  one  invariable  proof  of  its  presence  is  the  finding  of  food  remains 
or  hypersecretion  fluid  in  the  fasting  state,  whereas  in  atony  the  fasting 
stomach  is  empty.  In  100  of  the  writer's  cases  in  which  examination 
of  the  fasting  stomach  was  made,  in  82  the  stomach  was  absolutely 
empty,  in  14  were  found  small  quantities  of  fluid  under  20  c.c,  giving 
acid  reaction  but  not  containing  microscopical  or  macroscopical  food 
remains.  Ten  of  these  14  patients  were  gastroptotic.  In  96  per  cent, 
of  the  cases,  therefore,  the  fasting  stomach  was  practically  empty. 
In  4  patients  onl}'  was  there  found  fluid  over  30  c.c,  and  in  each  of 
these  4  patients  a  chronic  appendicitis  could  be  demonstrated. 

The  test  breakfast  is  often  characterized  by  its  abundance  and  by 
the  increase  in  the  amount  of  fluid  which  it  contains.  An  excessive 
amount  of  test  breakfast  return  is  not,  however,  apparent  in  the  majorit}^ 
of  instances.  In  three-fourths  of  the  writer's  patients  the  amount  of  test 
breakfast  removed  was  less  than  65  c.c.  It  cannot  be  said,  however,  that 
the  amount  of  test  breakfast  removed  by  aspiration  represents  the  total 
amount  of  food  contained  in  the  stomach  at  the  time  of  the  test,  for 
it  is  more  difficult  to  aspirate  the  contents  of  an  atonic  stomach  than 
if  the  organ  be  of  normal  tone.  To  determine  the  quantity  of  food 
remaining  in  the  stomach  after  the  withdrawal  of  the  test  breakfast, 
tests  for  motility  may  be  employed,  which  will  be  shortly  described. 
The  test  breakfast,  on  standing,  usually  separates  into  two  layers, 
the  upper  fluid  layer  being  equal  in  depth  to  that  of  the  sedimentary 
layer  in  contrast  to  the  normal  test  breakfast  in  which  the  supernatant 
fluid  is  rarely  over  half  the  depth  of  the  sediment.  The  breadstuff s, 
as  a  rule,  are  well  digested  and  homogeneous.  It  is  said  that  in  atony 
hyperacidity  is  the  rule.  This  is  not  according  to  the  writer's  exj)erience 
of  100  cases  of  atony: 


DIAGNOSIS 


323 


Total  acidity  was  10  to    20  in 4  cases 

Total  acidity  was  20  to    30  in  .      .      .                        .      .        5  cases 

Total  acidity  was  30  to    40  in 10  cases 

Total  acidity  was  40  to    50  in 24  cases 

Total  acidity  was  50  to    60  in 17  cases 

Total  acidity  was  60  to    70  in 19  cases 

Total  acidity  was  70  to    80  in 12  cases 

Total  acidity  was  80  to    90  in 8  cases 

Total  acidity  was  90  to  100  in 0  cases 

Total  acidity  was  100  to  110  in lease 

On  analyzing  this  table  it  is  seen  that  subacidity  was  present  in 
19  per  cent.,  normal  acidity  in  60  per  cent.,  hyperacidity  in  21  per  cent. 


Fig.  59 

Bbi 

3n 

^^^^^>i[^^B 

^H 

'     :'     iHfl 

f^ 

HP 

^^^^Hi' 

i 

Test  breakfast  in  uncomplicated  mild  atony.      The  breadstuffs  are  well  digested  and  unmixed 
with  mucus.     Acidity  normal.     Moderate  hjTjersecretion. 


Tests  for  Motility. — The  older  methods  of  testing  the  motility  of 
the  stomach  by  giving  capsules  of  salol  and  iodipin  which  pass  unchanged 
through  the  stomach,  disintegrate  in  the  duodenum,  become  absorbed, 
and  appear  in  the  urine  or  perspiration,  are  too  inaccurate  to  require 
much  consideration,  and  they  have  been  totally  abandoned. ,  The  only 
tests  for  motility  are  those  by  the  .r-ray  and  by  the  use  of  the  tube. 

Detection  of  bismuth  meal  within  the  stomach  at  different  periods  of 
time  after  it  has  been  eaten  is  the  only  positive  and  accurate  method 
of  determining  gastric  motility,  but  it  is  unfortunately  a  method  that 
cannot  be  used  as  a  routine  form  of  examination. 

Riegel's  test  is  based  on  the  assumption  that  the  normal  stomach 
should  be  empty  seven  hours  after  a  test  dinner  consisting  of  soup, 
beefsteak,  and  bread,  but  that  in  conditions  of  atony,  remains  of  this 
meal  are  found  in  the  stomach  at  the  expiration  of  this  time.  Riegel's 
test  is  simple,  and  would  be  quite  satisfactory  were  it  not  for  the  fact 


324  ATONY  OF  THE  STOMACH 

that  the  examination  of  the  patient  exactly  seven  hours  after  a  meal 
is  often  at  a  most  inconvenient  time.  A  simple  modification  of  Riegel's 
test,  employed  by  the  writer,  is  as  follows: 

The  patient  is  directed  to  take  for  breakfast  at  7.30  a.m.  a  cup  of 
coffee  with  milk  and  sugar,  a  chop  or  a  small  piece  of  steak,  and  a  break- 
fast roll.  Thereafter  nothing  is  to  be  taken,  not  even  water,  until 
the  examination  at  1  p.m.,  five  and  a  half  hours  after  the  meal.  Under 
normal  conditions  the  stomach  is  then  empty  or  contains  less  than 
20  c.c.  of  food  remains.  Quantities  of  residue  greater  than  this 
indicate  motor  error. 

IMathieu  and  Reymond  have  devised  a  test  to  calculate  the  amount 
of  residue  left  in  the  stomach  after  the  withdrawal  of  the  ordinary 
test  breakfast,  by  determining  the  acidity  of  the  test  breakfast  itself, 
and  the  acidity  of  residual  breadstuffs  washed  out  by  a  definite  quantity 
of  water.  The  test  breakfast  is  removed  by  aspiration  at  the  proi)er 
time  by  the  ordinary  method,  and  the  contents  laid  aside.  A  funnel 
is  then  attached  to  the  tube  and  200  centimeters  of  water  are  run  into 
the  stomach.  The  funnel  is  then  lowered  and  raised,  allowing  the  fluid 
to  flow  to  and  fro  so  that  a  thorough  admixture  of  fluid  and  residual 
breadstuffs  in  the  stomach  takes  place.  The  whole  quantity  is  then 
aspirated  and  the  total  acidity  of  each  specimen  is  determined.  If 
"b"  represents  the  quantity  of  the  undiluted  test  breakfast  and  "a" 
its  acidity,  and  if  "q"  represents  the  quantity  of  water  introduced 
(in  this  instance  being  200  c.c),  and  a'  the  acidity  of  this  diluted  food 
residue,  it  is  evident  that  the  2  acidities  a  and  a'  must  be  directly 
proportionate  to  the  quantities,  because  the  greater  the  quantity  of 
water  used  for  dilution  the  smaller  is  the  total  acidity  of  the  diluted 
food.    This  ultimate  formula  is  obtained: 

a'q 


By  adding  this  residual  amount  to  the  volume  of  the  test  breakfast 
originally  Avithdrawn,  the  total  amount  of  test  meal  in  the  stomach 
may  be  determined.  For  example,  through  the  tube  are  withdrawn 
60  c.c.  of  test  breakfast.  Having  the  acidity  of  48,  the  acidity  of  the 
diluted  contents  is  found  to  be  14.  The  formula  is  then  expressed  as 
follows: 

14  X  200  2800 

X  =    =  =82 

48— H  34 

'llw  total  (jiunititx  therefore  is  (iO  c.c.,  the  undiluted  contents  plus 
<S2  the  diluted  contents,  or  142  c.c.  of  test  breakfast  r(>niaining  in  the 


COURSE  825 

stomach  one  hour  after  the  meal  has  heeii  taken.  I'nder  normal  con- 
ditions,  the  total  quantity  of  the  test  breakfast  thus  ()l)taine(l  should 
not  exceed  200  c.c.  Quantities  exceeding  this  amoimt  indicate  motor 
insufficiency. 

This  test  is  not  accurate  when  mt)tor  error  is  accompanied  by  hyper- 
secretion, and  should  therefore  not  be  employed  in  any  case  in  which 
this  complication  is  present.  Being  based  on  the  estimations  for  acidity, 
it  is  naturally  not  applicable  to  those  in  which  motor  insufficiency 
coexists  wdth  an  absolute  of  hydrochloric  acid. 

A  very  simple  method  of  estimating  the  motility  of  the  stomach  has 
been  suggested  by  Eisner  and  has  been  adopted  by  the  writer  as  a  routine 
test.  The  test  breakfast  is  withdrawn  in  the  usual  manner,  a  Politizer 
bag  containing  200  c.c.  of  water  is  then  connected  with  the  tube  and 
the  water  injected.  By  allowing  the  fluid  to  be  sucked  back  into  the 
bulb  and  then  reinjected  several  times,  a  thorough  admixture  of  the 
water  with  the  gastric  cojitents  takes  place,  after  which  the  total  con- 
tents are  withdrawn  and  poured  into  a  graduate  glass.  The  original 
test  breakfast  is  poured  into  another  glass  and  both  specimens  allowed 
to  settle,  after  w^hich  the  amount  of  sediment  in  both  specimens  is 
determined.  A  total  residue  of  100  c.c.  may  be  normal.  Residues 
of  100  to  125  c.c.  are  on  the  borderline,  quantities  exceeding  125  c.c, 
indicate  motor  error. 

By  any  of  these  tests  for  gastric  motility,  it  may  be  demonstrated 
that  the  exit  of  food  from  atonic  stomachs  is  tardy,  although  complete, 
if  sufficient  time  be  allowed  to  elapse.  In  other  cases,  even  though  the 
subjective  symptoms  of  the  disorder  are  present,  the  food  seems  to  leave 
the  stomach  within  proper  time  limits,  so  that  a  negative  result  obtained 
by  any  of  the  tests  for  motility  does  not  necessarily  exclude  gastric  atony. 

Course. — The  course  of  the  disease  varies  from  the  expression  of  a 
slight  and  transient  complaint  to  that  of  a  chronic  and  harassing 
disorder. 

1.  Recurring  atony  may  occur  in  individuals  of  nervous  organization, 
especially  in  those  who  are  burdened  by  the  enteroptotic  habit,  at 
intervals  throughout  their  entire  life.  These  are  the  instances  of  delicate 
digestions,  easily  upset  and  slow  of  recovery.  Such  patients,  generally 
neurasthenic,  anemic,  and  undernourished,  are  always  forced  to  live 
quietly  and  eat  carefully  to  avoid  trouble,  and  yet  in  spite  of  all  their 
care  they  will  suffer  if  they  become  tired  or  nervous. 

2.  Acute  atony  from  transient  causes  is  often  o\-erlooked.  After 
anesthesia,  atony  is  almost  regularly  present,  but  usually  subsides 
within  twent}'-four  hours.  When  postanesthetic  \'omiting  persists 
after  this  time  the  existence  of  an  enlarged  atonic  stomach  can  regularly 
be  demonstrated.    Atony  may  reappear  on  the  third  to  fifth  day  after 


32G  ATONY  OF  THE  STOMACH 

the  operation,  dating  from  the  time  at  which  soUd  food  was  gi\'en. 
Gas,  nausea,  heaviness  of  the  stomach  after  eating,  and  lack  of  appetite 
are  the  ordinary  symptoms  observed. 

After  sudden  mental  shocks,  or  excessive  fatigue,  the  patient  may 
feel  too  tired  to  eat.  After  the  meal  the  food  lies  heavily  upon  the 
stomach,  and  occasions  distress  and  flatulence.  In  these  cases  psj'chic 
disturbances  of  gastric  secretion  are  often  present,  so  that  the  food 
is  improperly  digested.  Diarrhea  may  succeed  such  an  attack.  After 
several  days  the  normal  tonicity  of  the  stomach  may  return,  but  in 
other  cases  the  symptoms  of  atony  exist  for  weeks  after  the  apparent 
cause  has  disappeared.  In  acute  illness  a  diminished  and  easily  appeased 
appetite  with  gaseous  distention  of  the  stomach  may  indicate  an 
existing  atony.  If  too  excessive  quantities  of  liquid  by  mouth  be 
allowed,  prolonged  or  permanent  atony  may  result. 

3.  When  atony  is  once  firmly  established  the  symptoms  are  apt  to 
continue  without  any  cessation,  less  marked  during  the  vacation  months 
or  at  times  of  comparative  ease,  and  more  distressing  during  the  times 
of  greatest  stress  and  responsibilities,  but  never  interrupted  by  com- 
plete freedom  for  any  length  of  time.  Improvement  may  be  expected 
from  treatment,  but  the  disorder  is  apt  to  recur  whenever  any  extra 
mental  or  physical  strain  is  thrown  on  the  individual  in  the  performance 
of  his  daily  allotted  task. 

Treatment. — Atony  is  essentially  a  functional  reaction  of  the  stomach 
consequent  upon  the  wear  and  tear  of  daily  life,  and  the  more  we  are 
impressed  with  this  fundamental  idea  the  better  will  be  the  results  of 
our  treatment.  Every  individual  has  his  normal  limitations,  some  more 
and  some  less,  and  our  chief  object  should  be  to  see  to  it  that  as  far 
as  possible  the  patient  should  live  well  within  these  limitations.  Those 
with  the  enteroptotic  hal)it  and  those  with  delicate  sensitive  organiza- 
tions are  especially  unable  to  withstand  shocks  and  trials  of  life.  A 
careful  personal  inciuiry  should  therefore  be  made  as  to  daily  routine, 
and  every  habit  or  circumstance  that  tends  to  diminish  nervous  or 
physical  force  should  be  corrected  as  far  as  may  be  possible.  Physical 
or  nervous  expenditures  should  be  compensated  by  adequate  rest.  No 
amount  of  medical  treatment,  however  scientifically  conducted,  will 
prove  beneficial  if  the  patient  be  allowed  to  waste  energy  and  strength 
and  to  use  up  nervous  capital. 

Dietetic  Treatment. — -The  principle  of  the  dietetic  treatment  is  to 
conserve  the  muscular  power  of  the  stomach  by  not  overloading  the 
weakened  organ  by  too  much  food  at  any  one  time,  but  to  distribute 
the  burden  through  the  day  by  small  and  frequent  meals. 

The  bulk  of  the  weight  of  the  food  should  not  be  increased  by  copious 
draughts  of  fluid  taken  with  the  meals.     Restriction  of  liquids  is  an 


TREATMENT  327 

essential  part  of  the  treatment.  The  patient  may  drink  between  meals 
if  he  be  thirsty,  but  never  more  than  half-glass  at  a  time.  The  maximum 
amount  of  liquid  at  any  one  meal  should  not  exceed  one  glass.  Excessive 
drinking  "to  flush  the  system"  should  be  absolutely  interdicted. 

The  quantity  of  each  meal  depends  largely  upon  the  degree  of  the 
atony.  In  mild  cases  a  meal  smaller  than  the  average,  but  with  a 
restricted  amount  of  liquids,  may  be  taken  three  times  a  day  at  the  con- 
ventional hours,  and  small  meals  allowed  in  the  forenoon  and  afternoon. 
Eating  at  bedtime  is  generally  inadvisable  as  it  may  increase  the 
distention  during  the  night  and  prevent  sleep.  Coffee  may  be  allowed 
for  breakfast;  soup  at  luncheon  or  dinner  should  be  prohibited.  A 
sample  diet  for  mild  atony  is  as  follows: 

8  A.M.  Cup  of  coffee,  or  cocoa,  with  cream  and  sugar,  fine  cereal. 

11  A.M.  Egg-shake,  Russell's  emulsion,  or  koumys. 
1  P.M.  Steak  or  chop,  one  vegetable,  rice  pudding,  bread  and  butter. 
4  P.M.  Chicken  sandwich  and  a  glass  of  hot  milk. 

7  P.M.  Fish  or  chicken,  two  green  vegetables,  tapioca  pudding. 
In  more  advanced  atonies  the  bulk  of  the  larger  meals  should  be  still 

further  reduced,  and  if  possible  the  size  of  the  smaller  meals  should  be 
increased.    A  sample  diet  may  be  thus  given: 

8  A.M.  Cup  coffee,  or  cocoa  with  cream  and  sugar,  soft-boiled  egg, 
bread  and  butter. 

11  A.M.  Baked  custard. 
1  P.M.  Minced  chicken  on  toast,  corn-starch  pudding. 
4  P.M.  Scraped  beef  sandwiches. 
7  P.M.  Small  broiled  chop,  creamed  spaghetti. 

10  P.M.  Cup  of  malted  milk. 

The  quality  of  food  makes  very  little  difference  if  the  bulk  of  the 
meal  be  reduced,  as  the  digestive  power  of  the  gastric  juice  is  normal 
or  hyperpeptic  in  four-fifth  of  the  cases. 

Food  that  is  tough,  gristly,  and  indigestible  should,  however,  in  all 
cases  be  interdicted,  as  undigested  lumps  are  rejected  by  the  pylorus 
and  remain  abnormally  long  in  the  stomach.  Thorough  and  leisurely 
mastication  for  the  same  reason  must  be  enjoined,  and  the  teeth  put 
in  good  condition  for  the  task.  Hasty  eating  and  the  bolting  of  food 
are  distinctly  detrimental.  If  achylia  should  coexist,  meats  should  be 
cut  out  from  the  diet  and  replaced  by  carbohydrates  of  equal  caloric 
values  as  described  in  full  under  achylia. 

If  the  gastric  secretions  are  well  preserved,  meats  may  be  given 
freely,  although  the  writer  usually  interdicts  the  use  of  beef,  and  the 
heavier  red  meats,  owing  to  the  large  amount  of  indigestible  connecti^'e- 
tissue  fiber  which  they  contain,  and  replaces  them  by  chicken,  fish, 
lamb,  or  tender  lean  broiled  or  boiled  ham.      Under  no  circumsiances 


328  ATONY  OF  THE  STOMACH 

should  ihe  diet  be  so  restricted  that  the  patient  loses  weight.  The  tendency 
of  atonic  patients  is  to  attribute  their  (Hstress  to  what  they  eat  and 
accordingly  to  reduce  their  diet.  The  more  they  starve  the  weaker 
they  become  and  the  more  atonic.  Patients  should  be  encouraged  to 
eat  enough  to  maintain  body  weight,  or  preferably  to  gain  in  their 
nutrition,  nor  should  the  diet  advised  be  so  monotonous  as  to  create 
a  distaste  for  food.     Individual  tastes  must  be  considered. 

It  has  been  recommended  to  place  atonic  cases  on  a  purely  milk  diet, 
given  8  to  10  ounces  e\'ery  two  hours  so  that  2  quarts  are  taken  daily. 
The  writer  is  absolutely  and  unalterably  opposed  to  this  line  of  treat- 
ment, as  the  coagula  are  firm  and  tough,  owing  to  normal  preservation 
of  lab-ferment  and  are  retained  too  long  within  the  stomach,  and  more- 
over unless  milk  be  given  in  at  least  double  this  quantity  the  total 
caloric  ^'alue  is  quite  insufficient  to  maintain  weight  and  strength. 
Two  quarts  of  milk  represent  less  than  1500  calories,  supposing  the  milk 
to  be  of  extra  richness,  whereas  at  least  2500  calories  are  required  to 
meet  the  demands  of  body  expenditure. 

^Yhen  the  diet  is  conducted  on  these  lines,  there  is  usually  a  marked 
improvement  in  the  distress  and  distention.  In  other  cases  no  improve- 
ment whate\'er  can  be  noted  so  long  as  the  patient  is  up  and  around. 
A  week  or  so  of  absolute  physical  rest  in  bed  is  then  indicated,  and 
usually    is   attended  by  satisfactory  results. 

Medical  Treatment. — Medical  treatment  is  of  less  importance  than 
the  dietetic  or  physical.  Theoretically  nux  vomica  or  strychnine  are 
indicated  to  increase  the  motor  power  of  the  stomach,  and  although 
often  disappointing  in  its  results,  apparent  benefit  follows  the  use 
of  this  drug  in  many  cases.  The  tincture  or  extract  of  nux  vomica  or 
similar  preparations  of  physostigma  may  be  employed,  and  these 
preparations  seem  to  be  somewhat  more  efficacious  than  either  strych- 
nine or  eserine  in  isolated  form. 

The  following  prescription  may  be  employed: 

\\ — Tincture  physostigma 3v 

Elixir  calisaya ad     5iv 

M.     8ig. — Tcaspoonful  in  a  wineglass  of  water  after  meals  three  times  a  day. 

}\ — Tinet.  nux  vomiea ov 

Sod.  glycerophosphate 3v 

Elixir  diazyine  (Kairchild) 5iv 

Aquae ad     gviij 

M.     Sig. — Tablespoon ful  in  water  after  eating,  three  times  a  day. 

Should  anacidity  coexist,  diluted  hydrochloric  acid  or  oxyntin  may 
be  employed.  When  gastric  secretion  is  maintained  the  degree  of  acidity 
is  rarely  excessive,   nor  is  a  contiiuioiis  hyjjersecretion  apt  to  occur. 


T  RE  ATM  EXT  329 

so  that  it  is  rarely  necessary  to  give  alkalies.  Bicarbonate  of  soda  or 
magnesia  may,  however,  be  advised  should  the  patient  complain  of 
heart-burn  or  pyrosis. 

Anemia  should  be  combated  by  preparations  of  iron,  though  large 
doses  should  not  ordinarily  be  advised.  Constipation  should  be  con- 
trolled by  diet  and  massage  rather  than  by  drugs  if  possible.  When 
laxatives  are  necessary,  the  mildest  forms  of  medication  should  alone 
be  used  and  in  the  smallest  possible  doses.  Every  medicinal  laxative 
tends  to  i)erpetuate  atony.  Salines  should  be  administered  cautiously. 
Enemas  though  having  their  disadvantages  seem  to  the  writer  less 
objectionable  than  overmedication  by  mouth.  The  quantity  injected 
should  not  exceed  2  pints,  and  the  enema  given  lying  down.  Enemas 
given  in  the  sitting  posture  are  not  to  be  advised. 

The  writer  has  endeavored  to  stimulate  intestinal  peristalsis  by  the 
use  of  peristaltic  hormones. 

Fairchild  has  prepared  for  the  writer  some  preparations  of  the 
hormones:  secretion  (Starling  and  Bayliss),  which  he  has  used  for 
some  time,  and  more  recently  the  peristaltic  hormone  of  Zuelzer.  He 
has  used  these  two  hormones  in  combination  with  the  bile  salts 
(Fairchild)  with  good  results.  This  combination  has  been  prepared 
in  capsules,  each  containing  bile  salts  ^  gr.,  secretion  1  gr.,  hormone 
peristaltic  10  gr. 

The  peristaltic  hormone  has  also  been  used  in  injections  prepared 
in  ampoules,  each  containing  5  c.c.  The  sterile  fluid  (in  physiological 
salt  solution)  is  taken  up  into  the  sterilized  ampoule  and  immediately 
sealed. 

In  the  present  state  of  our  knowledge  of  the  chemistry  of  the  hormones 
and  the  fact  of  the  ready  susceptibility  of  these  principles  to  change, 
these  special  preparations  have  been  prepared  in  small  quantities  only 
from  time  to  time  and  sent  directly  from  the  laboratory  to  the  pharmacist 
as  required. 

Physical  Treatment. — 1.  Rest  is  to  be  insisted  on  in  every  case  as 
an  antidote  for  overactivity.  Rest  should  regularly  succeed  exercise, 
especially  before  eating,  so  that  the  patient  is  refreshed  at  the  time  of 
the  meal.  It  may  be  necessary  for  the  patient  to  be  in  bed  for  at  least 
two  hoiirs  after  the  mid-day  meal  before  any  improvement  from  the 
treatment  is  apparent.  Exercise  directly  after  eating  should  always 
be  prohibited.  In  severe  degrees  of  atony  in  run-down  individuals, 
a  rest  cure  becomes  a  matter  of  necessity  and  should  be  conducted  along 
the  lines  recommended  under  the  treatment  of  gastroptosis. 

Intragastric  faradism  was  formerly  employed  more  frequently  than 
at  the  present  time.  The  writer's  introgastric  electrode  consists  of  a 
perforated   hard-rubber  capsule  containing  a  metallic  tip  to  which  is 


330 


ATONY  OF  THE  STOMACH 


attached  a  spiral  of  fine  ])iano  wire  covered  with  rubber  tubing,  so  as  to 
be  both  small  in  caliber  and  extremely  flexible.  The  electrode  is  easily 
introduced  and  creates  after  one  or  two  introductions  little  or  no 
discomfort.  A  large  moist  pad  is  then  placed  over  the  epigastrium 
and  a  slowly  interrupted  faradic  current  passed,  of  sufficient  intensity 
to  produce  visible  contractions  of  the  abdominal  wall.  The  action  is 
increased  b.y  the  sipping  of  water  from  time  to  time.  The  applications 
should  never  be  made  within  two  hours  after  eating,  and  the  duration 
of  the  seance  should  not  exceed  fifteen  minutes.  The  writer  had  a  long 
experience  in  intragastric  faradism,  at  first  employing  the  treatment 
with  an  enthusiasm,  wdiich  has  steadily  diminished,  so  that  at  the 
present  time  he  has  practically  abandoned  its  use. 


Fig.  60 


Writer's  intragastric  electrode. 


In  gastric  atony  lavage  is  contraindicated,  as  the'  introduction  of 
water  in  bulk  tends  to  sag  and  overdistend  the  weakened  organ.  In 
the  majority  of  cases  of  atony,  food  is  well  digested  and  not  mixed 
with  sufficient  gastric  mucus  to  call  for  tlie  mechanical  cleansing.  If 
demonstrable  mucous  gastritis  coexists,  lavage  may  be  employed,  but 
the  majority  of  water  induced  at  any  one  time  should  be  very  small, 
not  over  8  ounces,  and  care  should  be  taken  that  an  equal  quantity 
is  reclaimed.  Mineral  waters  have  no  place  in  therapy  of  atony;  they 
are  distinctly  and  absolutely  contraindicated. 

Massage  is  of  considerable  service  if  skilfully  done.  Deep  and  forcible 
massage  with  the  ends  of  the  fingers  should  be  prohibited  and  the 
physician  should  be  careful  that  the  massage  is  not  too  violent. 

Hydrotherapy  is  a  valuable  addition  to  the  treatment.  A  simple 
expedient  is  for  the  ])atient  on  rising  in  the  morning  to  lie  for  a  moment 
or  two  in  hot  water  and  then  take  a  cold  shower  or  to  pour  cold  water 
from  a  j)itcher  down  the  back  whih'  ten  is  slowly  counted.  A  strenuous 
course  of  hydrothcraj^N'  in  institutions  devoted  to  this  form  of  treat- 


TREATMENT 


331 


ment  is  not  gentTally  advisable,  as  the  patients  are  apt  to  react  badly 
after  the  first  stimulating  effect  has  passed. 

The  symptoms  of  intestinal  auto-intoxication  are  often  improved  by 
intestinal  irrigations.  Irrigations  are  often  given  by  the  use  of  two 
rectal  tubes,  the  inflow  being  through  one,  the  outflow  through  the  other. 
While  water  is  easily  introduced  into  the  bowel,  it  is  not  so  easy  to  get 
rid  of  it  unless  the  exit  tube  be  of  large  caliber  so  that  it  does  not  be- 
come blocked.  One  such  tube  is  quite  enough  to  pass  into  the  bowel  at 
one  time;  hence,  the  writer's  objection  to  the  double  tube.  A  single  large 
tube  should  be  used  with  a  to-and-fro  current.  The  size  of  tube  often 
employed  is  quite  too  small  and  becomes  easily  blocked,  so  that  the 
water  introduced  remains  in  the  bowel,  much  to  the  patient's  discom- 
fort.   The  writer's  apparatus  for  intestinal  irrigation  is  as  follows: 


Fig.  61 


EXIT  TUBE 


IRRIGATOR 


STOPCOCK  A 


"Author's  irrigation  outfit.  By  closing  stop-cock  B  and  opening  stop-cock  A  the  fluid  enters  tlie 
colon.  After  a  sufficient  quantity  has  been  introduced  by  closing  stop-cock  A  and  opening  stop-cock 
B  the  fluid  flows  out  into  a- large  collecting  jar." 


A  rectal  tube  of  the  requisite  size  is  attached  to  a  glass  T-tube,  one 
of  the  other  arms  of  which  is  attached  to  an  irrigating  jar  of  at  least 
one  liter  capacit}-,  the  other  to  a  soft-rubber  tube  about  4  feet  in  length. 
Pinch  cocks  are  placed  on  the  inflow  and  outflow  tubes.  The  rectal 
tube  is  then  inserted  about  6  to  8  inches,  and  the  apparatus  held  in 
position  on  the  side  of  the  bed  by  long  pins.  The  outflow  cock  is  closed 
and  about  one  pint  of  water  allowed  slowly  to  fill  the  bowel.  The  inflow 
cock  is  then  closed  and  the  outflow  cock  opened  so  that  the  water  is 


332 


ATONY  OF  THE  STOMACH 


allowed  to  run  out,  and  the  process  repeated.  Six  to  eight  quarts  of 
water  are  used  at  each  treatment  and  an  estimation  made  of  the 
difference  between  the  amount  that  is  injected  and  the  amount  that 
is  returned  so  that  the  difference  representing  the  retained  fluid  does 
not  exceed  one  pint. 

Fig.   02 


N 


Aut)ior's  colon  tube.     Actual  size.     Notice  large  caliber  and  ample  size  of  the  ope. 
for  good  drainage. 


Fig.  6.3 


Author's  modification  of  the  Kemp  tube. 


An  irrigation  so  given  demands  the  assistance  of  a  nurse  or  attendant 
and  therefore  is  not  always  practicable. 

For  purpose  of  home  use  without  the  help  of  an  attendant  the  writer 
has  devised  a  modification  of  Kemp's  tube,  by  increasing  the  vertical 
dimensions  of  the  instrument,  by  enlarging  the  eye,  and  by  carrying 
the  inflow  tube  along  the  upper  portion  of  the  instrument  so  that  it 
does  not  block  tlie  centre  of  the  eyes,  as  does  Kcm])'s  Instrument. 


CHAPTER  XI 
ACUTE  DILATATION  OF  THE  STOMACH 

Synonyms. — Arteriomesenteric  ileus,  acute  gastrectasis,  duodeno- 
jejunal obstruction,  postoperative  gastric  dilatation,  gastrojejunal 
obstruction,  duodenal  ileus,   mesenteric  ileus. 

Acute  dilatation  of  the  stomach  was  formerly  regarded  as  somewhat 
of  a  rarity,  Laffer,  in  1908,  having  found  but  217  cases  recorded  in 
literature.  The  reported  cases  up  to  this  time  were  chiefly  those  with 
a  fatal  outcome,  the  mortality  being  63.5  per  cent,  of  the  cases  in  which 
the  symptoms  were  distinctive  and  obvious.  During  the  last  few  years, 
however,  numerous  cases  have  been  reported  of  undoubted  acute 
dilatation,  in  which  the  symptoms  while  characteristic  were  less  severe 
and  eventuated  in  recovery.  It  is  even  believed  at  the  present  time 
that  many  instances  of  postoperative  vomiting  are  examples  of  this 
disorder.  When  these  facts  therefore  are  taken  into  consideration  we 
are  led  to  the  belief  that  acute  dilatation  is  not  at  all  an  uncommon 
event. 

Pathology. — The  most  striking  phenomenon  observed  at  the  autopsy 
is  the  enormous  dilatation  of  the  stomach  so  that  it  may  occupy  nearly 
the  entire  abdomen  and  may  even  extend  to  the  pelvis.  The  dilated 
organ  is  usually  bent  into  two  unequal  portions,  one  comprising  the 
greater  part  of  the  stomach,  extending  almost  perpendicularly  down- 
ward, and  a  smaller  portion  consisting  of  the  pyloric  and  extending 
upward  and  to  the  right  at  an  acute  angle,  giving  the  dilated  viscus 
a  V-shape,  which  has  been  likened  to  a  fat  arm  flexed.  The  surface 
of  the  stomach  may  be  congested  and  covered  with  dilated  bloodvessels 
or  may  be  pale  in  appearance.  In  a  little  over  half  the  cases  the  duo- 
denum is  dilated  in  whole  or  in  part.  In  the  majority  of  instances  the 
duodenal  dilatation  stops  at  the  point  where  the  duodenum  is  com- 
pressed between  the  root  of  the  mesenter}'  and  the  superior  mesenteric 
artery  in  front,  and  the  aorta  and  vertebral  column  behind.  In  other 
cases  the  dilatation  extends  past  this  point  to  the  lower  duodenum 
or  even  the  upper  portion  of  the  jejunum.  The  intestine  below  is  almost 
invariably  empty  and  collapsed,  there  being  but  one  case  (Mahomet's) 
in  which  the  intestines  were  dilated  throughout  their  course.  The 
pylorus  is  regularly  patent  and  no  organic  stenosis  is  found  in  the 
lumen  of  the  duodenum. 


334 


ACUTE  DILATATION  OF  THE  STOMACH 


At  the  spot  where  the  root  of  the  mesentery  and  its  contained  superior 
mesenteric  artery  and  veins  cross  the  duodenum  there  is  normally 
a  moderate  degree  of  compression  exerted  sufficient  to  hold  back  the 
bile  and  pancreatic  juice  for  a  certain  time  after  meals.  When  the 
stomach  begins  to  empty  itself  one  and  a  half  to  three  hours  after  eating, 
the  entrance  of  chyme  into  the  duodenum  causes  sufficiently  strong 
contractions  of  the  duodenal  wall  to  overcome  the  resistance  at  the 
compression  point  and  to  force  its  contents  into  the  jejunum.  Under 
abnormal  conditions  this  mesenteric  compression  may  become  so  ex- 
treme that  the  muscular  forces  above  the  point  are  powerless  to  over- 
come the  obstruction,  and  dilatation  of  the  stomach  and  the  duodenum 


Fig.  64 


Acute  primary  dilntatidii  ol  ihc  stomach  associated  with  piicmiKmia.      (From  Thomson.) 


proximal  to  the  (•omi)ression  point  ensues.  The  most  common  cause 
for  an  increased  mesenteric  compression  of  the  duodenum  is  traction 
on  the  root  of  the  mesentery  by  a  descent  of  the  intestines  into  the 
pelvis.  This  mesenteric  constriction  can  be  experimentally  produced 
by  traction  on  the  root  of  the  mesentery  by  a  weight  of  500  gm., 
equivalent  to  that  of  the  small  intestine. 

Mechanism  of  Acute  Dilatation  of  the  Stomach. — The  mechanism 
of  acute  gastric  dilatation  is  an  interesting  sul)ject  which  has  been 
provocative  of  much  discussion  and  argument,  but  about  which  at 
present  time  we  know  comparatively  little.  Two  conflicting  opinions 
are  expressed : 


MECHANISM  OF  DILATATION  OF   THE  STOMACH  335 

1.  That  the  dilatation  is  (kie  to  an  occhisiou  of  the  (hiodeniun 
resulting  from  its  compression  by  the  traction  of  the  root  of  the  mes- 
entery, or  by  the  pressure  of  the  superincumbent  and  dilated  stomach 
on  those  parts  of  the  duodenum  which  lie  in  contact  with  the  front 
and  left  side  of  the  spinal  column.  In  other  and  rarer  cases,  the  dila- 
tation may  be  produced  mechanically  by  duodenal  kinks. 

2.  That  the  dilatation  is  the  result  of  paresis  of  the  gastric  wall 
either  peripheral  and  analogous  to  the  meteorism  of  the  intestine  that 
occurs  with  typhoid  fever,  or  central  and  due  to  the  diminished  motor 
impulses  conveyed  to  the  stomach  through  the  vagus  nerve. 

The  various  causes  suggested  may  be  tabulated  as  follows: 

1.  Mechanical  causes. 

(a)  Arteriomesenteric  constriction  (favored  by  lordosis). 
(6)  Duodenal  kinks. 

(c)  Mechanical  weight  of  stomach  on  duodenum  (favored  by 

counterpressure  as  in  plaster  jackets). 

(d)  Cardia  closure  by  folds  or  intragastric  pressure. 

2.  Paralytic  causes. 

(a)  Central: 

1.  Section  of  vagi. 

2.  Involvement  of  vagus   in   pneumonic   exudate. 

3.  Blows  or  head  injuries. 
(6)  Peripheral: 

1.  Operations  near  stomach  with  traumatism  or   slight 

septis. 

2.  Post-anesthetic. 

3.  Overdistention  by  excessive  eating  and  drinking. 

4.  Toxemic. 

Mechanical  Theory. — (a)  The  mechanism  of  mesenteric  constriction 
has  been  admirably  described  by  Conner,^  and  by  him  is  regarded  as 
the  most  important  cause  for  acute  dilatation. 

For  the  entrance  of  the  intestine  into  the  pelvis,  according  to  Conner, 
three  things  are  necessary:  a  dorsal  decubitus,  an  intestine  nearly  or 
quite  empty  of  gas  and  feces,  and  a  mesentery  of  sufficient  length  to 
enable  the  intestines  to  slip  into  the  pelvis.  There  is  no  doubt  that 
a  mesenteric  occlusion  of  the  duodenum  may  actually  occur,  for  in 
19  out  of  38  cases  in  which  the  duodenum  was  dilated,  actual  compres- 
sion was  found.  In  this  connection  a  case  reported  by  Baumler  is  im- 
portant, for  at  autopsy  he  found  a  band  of  bright  red  color  2  cm.  broad 
on  that  part  of  the  duodenum  which  ran  under  the  root  of  the  mesentery 
and  the  duodenal  mucosa  corresponding  to  this  band  showed  super- 

'  Amer.  Jour.  Med.  Sci.,  March,  1907,  p.  345. 


336  ACUTE  DILATATION  OF  THE  STOMACH 

ficial  pressure  necrosis.  Compression  of  the  duodenum  by  the  root 
of  the  mesentery  is  favored  by  a  forward  curve  of  the  vertebral  column 
as  in  lordosis. 

Although  it  is  regarded  by  many  that  the  duodenal  compression  thus 
induced  is  the  primary  cause  for  gastric  dilatation,  there  is  some  doubt 
as  to  whether  such  an  occlusion  may  not  be  the  result  of  the  dilatation 
rather  than  the  cause.  In  enteroptosis  we  have,  as  is  well  known, 
sagging  downward  of  the  small  intestines  and  traction  of  the  root  of 
the  mesentery,  but  in  spite  of  this  we  have  no  dilatation  of  the  stomach 
and  no  backward  filling  of  the  stomach  by  biliary  secretions.  In  250 
of  the  writer's  cases  of  gastroptosis  in  which  examination  of  the  fasting 
stomach  was  made,  in  not  a  single  instance  was  there  any  evidence  of 
a  backward  regurgitation  into  the  stomach  comparable  with  the  fluid 
vomited  by  those  who  suffer  from  acute  gastric  dilatation. 

It  is  claimed  that  fasting  and  purgation  enforced  before  an  operation 
allow  the  intestine  to  become  empty  and  collapsed  so  that  it  sinks 
readily  into  the  pelvis  and  pulls  on  the  root  of  the  mesentery.  This 
may  be  so,  but  there  are  many  other  instances  of  a  similar  collapsed 
condition  of  the  intestine  without  mesenteric  constriction,  such  as  after 
the  vomiting  and  purging  of  acute  gastro-enteritis,  or  the  collapsed 
intestine  of  starvation,  or  after  any  severe  or  continued  diarrhea. 
Moreover,  acute  dilatation  is  not  infrequent  with  pneumonia,  in  which 
disease  abdominal  tympanites  rather  than  intestinal  collapse  is  more 
usual. 

Other  mechanical  causes  besides  mesenteric  constriction  have  been 
found  to  explain  the  dilatation  in  other  cases,  and  were  noted  in  S  of 
38  cases  collected  by  Conner  in  which  the  dilatation  ceases  at  the  lower 
duodenum.  There  may  be  found  sharj)  kinks  at  the  duodenojejunal 
junction.  Such  a  cause  was  found  in  Petit's  case  and  was  relieved  by 
lifting  up  the  jejunum  and  stitching  it  to  the  transverse  mesocolon 
with  complete  recovery  of  his  patient.  In  other  cases  occasional  kinking 
at  the  junction  of  the  first  and  second  portion  of  the  duodenum  has  been 
noted.  Angulation  at  this  point  is  often  experimentally  produced  by 
the  forcible  dilatation  of  the  stomach  of  a  cadaver  with  air,  but  rarely 
resists  a  water  pressure  of  over  20  c.c. 

Box  and  Wallace^  have  reported  five  cases  in  w^hich  at  autopsy  the 
dilated  heavy  stomach  lay  upon  the  duodenum  and  compressed  it. 
The  gastric  dilatation  was  evidently  maintained  l)y  the  pressure  of  the 
stomach  on  the  duodenum,  since  on  raising  tlic  former  gas  immediately 
rushed  into  the  jejunum.  Box  and  Wallace  called  attention  to  the  fact 
that  the  compression  must  of  necessity  hv  greater  before  the  abdominal 

'  [.ancct,  .July  22,  1911. 


MECHANISM  OF  DILATATION  OF   THE  STOMACH  337 

ca^'ity  is  open,  owing  to  counter-pressure  exercised  by  the  abdominal 
muscles,  and  for  this  reason  experiments  on  the  cadaver  with  the  stomach 
exposed  only  reproduce  in  a  very  imperfect  manner  the  conditions 
present  during  life. 

Kelling  considers  that  a  valve-like  closure  of  the  cardia  by  folds  of 
mucous  membrane,  which  is  favored  by  the  oblique  insertion  of  the 
esophagus  into  the  stomach,  may  result  whenever  the  stomach  is  ex- 
perimentally inflated,  and  he  suggests  that  this  cardia  closure  in  dila- 
tation of  the  stomach  may  render  it  impossible  for  the  stomach  to  empty 
itself  of  its  contents.  There  can  be  no  doubt  that  in  some  of  the  recorded 
cases  air  and  fluid  were  contained  in  a  dilated  stomach  at  high  pressure. 
In  one  of  Laffer's  cases,  when  the  tube  entered  the  stomach  a  great 
quantity  of  gas  whistled  out,  followed  by  a  jet  of  black  fluid  that 
squirted  three  feet.  This  could  hardly  have  been  the  case  had  the 
cardia  been  normally  patent. 

jNIechanical  overloading  of  the  stomach  may  be  followed  by  its 
paralytic  overdistention.  Grundzach's^  patient  collapsed  from  this 
condition  after  eating  30  hard-boiled  eggs  and  drinking  a  considerable 
quantity  of  wine.  Minor  attacks  may  follow  overeating  by  gluttonous 
children. 

Paralytic  Theory. — Paresis  of  Central  Origin. — As  the  motor  impulses 
to  the  stomach  are  conveyed  through  the  vagus  nerve,  any  condition 
which  interferes  with  this  function  of  the  nerve  may  be  followed  by 
gastric  dilatation.  Paralytic  dilatation  of  the  stomach  in  dogs  has 
follow^ed  section  of  the  vagi  at  different  levels.  Several  instances  are 
reported  of  gastric  dilatation  following  injury  to  the  head,  supposedly 
from  paresis  of  the  motor  function  of  the  vagus.  The  frequency  of 
dilatation  occurring  during  the  course  of  lobar  pneumonia  is  explained 
by  some,  by  involvement  of  the  vagus  trunk,  by  exudation  into  the 
posterior  mediastinum. 

Paresis  of  Muscular  Wall. — Paresis  of  the  muscular  w^all  of  the 
stomach  may  result  from  prolonged  operative  procedure  in  the  neigh- 
borhood of  that  organ  and  may  therefore  be  considered  an  evidence 
of  local  traumatism. 

Postanesthetic  Pare,9i5.— Postanesthetic  paresis  is  supposed  to  be 
an  occasional  cause.  We  must  consider  in  this  connection  the  animal 
experiments  made  by  Kelling  and  Braun.  These  experimenters  in- 
flated the  stomach  of  dogs  upon  whom  gastrostomy  had  been  done  and 
found  that  whenever  a  certain  degree  of  distention  was  reached  vomiting 
reflex  was  excited  and  the  stomach  was  emptied  by  eructation  and  by 
vomiting.     When,  however,  the  animal  was  narcotized  the  vomiting 

'  Wion.  ined.  Presse,  1897,  No.  43,  p.  1350. 
22 


338  ACUTE  DILATATION  OF   THE  STOMACH 

reflex  was  abolished,  and  the  stomach  could  be  distended  to  the  point 
of  bursting  without  the  least  escape  of  air  or  stomach  contents  through 
the  esophagus. 

After  recovery  from  .the  anesthetic  there  is  usually  a  hyperexcit- 
ability  of  the  vomiting  centres.  After  a  variable  time  the  vomiting 
centres  become  again  normal,  but  occasionally  it  is  thought  conditions 
of  exhaustion  or  even  of  abolition  of  function  may  occur  which  may 
conduce  to  acute  dilatation.  When  an  anesthetic  and  an  operation 
are  associated  it  is  difficult  to  say  which  is  the  more  responsible  for 
the  event. 

Toxic  Paresis. — Toxic  paresis  may  be  autogenous  or  exogenous. 

Autogenous  toxemia  producing  muscular  paresis  of  the  stomach 
wall  may  result  from  auto-intoxication  by  poison  generated  within  the 
alimentary  canal.  While  this  cause  has  been  adduced  by  some,  the 
writer  has  not  been  able  to  satisfy  himself  that  it  has  been  an  opera- 
tive cause  in  any  of  the  reported  cases  of  which  he  has  knowledge. 

Exogenous  toxemia  is  becoming  recognized  as  probably  the  most 
important  factor  in  producing  acute  gastric  dilatation.  According 
to  this  theory,  the  infective  toxins  of  pneumonia  or  typhoid  fever, 
or  of  the  other  forms  of  septic  infection  act  as  paralyzers  of  the  gastric 
musculature  and  allow  of  atonic  dilatation.  Very  interesting  in  this 
connection  is  a  recent  communication  by  Rutz,^  in  which  is  described 
a  number  of  cases  of  pneumonia  in  which  pneumococci  were  found  in 
the  stools  associated  with  a  considerable  degree  of  abdominal  distention. 
According  to  this  writer  the  pneumococci  or  their  toxins  act  locally 
upon  the  wall  of  the  alimentary  tract  to  produce  a  moderate  degree 
of  paresis  with  resulting  distention. 

The  number  of  cases  reported  of  acute  dilatation  of  the  stomach 
complicating  pneumonia  is  increasing  every  year  and  constitutes 
one  of  the  commonest  types  of  the  disorder.  There  is  no  reason  in 
these  cases  for  supposing  that  the  intestines  shrink  and  drop  into  the 
pelvis,  thus  causing  traction  of  the  root  of  the  mesentery.  In  pneumonia 
there  is  more  usually  a  moderate  degree  of  abdominal  distention, 
which  should  hold  the  intestines  in  place.  It  is  probable,  therefore, 
that  the  dilatation  is  due  to  the  direct  effect  of  the  toxemia  and  that 
any  duodenal  occlusion  is  a  secondary  affair. 

LaflPer's  4  cases  were  all  se])tic,  one  postj)artum  case  with  sloughing 
of  the  abdominal  wall  following  injection  of  salt  adrenalin  solution,  the 
second  followed  abscess  of  the  antrum  with  pyemia  and  staphylococci 
in  the  blood  and  left  knee,  the  third  occurred  with  gangrenous  appendix, 
while  the  fourth  complicated  pyelitis  with  cystitis  and  pyelitis. 

'  Xcw  York  Med.  .lour..  .July  20,  1912,  p.  11.3. 


MECHANISM  OF  DILATATION  OF   THE  STOMACH  ;3.39 

Of  the  cases  reported  by  Box  and  Wallace  in  which  the  weight  of 
the  stomach  on  the  duodenum  was  apparently  the  cause  for  the  dila- 
tation, 3  were  decidedly  septic.  The  writer  is  impressed  on  reading 
the  reported  cases  with  the  remarkable  frequency  with  which  acute 
dilatation  occurs  in  the  course  of  various  forms  of  infectious  diseases 
or  conditions  of  sepsis.  In  abdominal  operations  the  septic  element 
may  not  be  sufficient  to  call  forth  evident  general  symptoms  of  such, 
but  nevertheless  slight  degrees  of  peritonitis  may  exist,  scarcely  more 
than  an  injection  of  the  serosa,  but  quite  sufficient  to  cause  a  definite 
muscular  paresis.  In  a  case  reported  by  Halsted^  dilatation  of  the 
stomach  and  first  portion  of  the  duodenum  followed  operation  for 
gallstones.  Accurately  corresponding  with  the  distended  portion  of 
the  bowel  was  a  slight  peritonitis  with  just  enough  exudate  to  cause 
adhesions  between  the  duodenum  and  gall-bladder. 

Summary. — In  review  of  what  has  been  said  concerning  the  mechanism 
of  acute  dilatation  and  the  various  causes  that  have  been  adduced  to 
explain  the  condition,  it  is  evident  that  no  one  single  cause  can  be 
applied  to  all  the  cases.    The  following  deductions  can  be  formulated. 

1.  In  rare  instances  mechanical  dilatation  of  the  stomach  may  be 
induced  by  excessive  eating  or  drinking  either  by  causing  a  paralytic 
overdistention  or  by  mechanical  pressure  of  the  overloaded  stomach 
upon  the  duodenum. 

2.  Mechanical  pressure  of  the  stomach  on  the  duodenum  is  favored 
by  counter-pressure  on  the  abdominal  wall,  explaining  the  relative  fre- 
quency with  which  the  accident  has  occurred  after  the  encasement 
of  the  body  by  a  plaster  jacket  in  orthopedic  cases. 

3.  Arteriomesenteric  constriction  by  traction  of  the  root  of  the  mes- 
entery from  downward  displacement  of  the  intestines  may  occur  in 
rare  instances  as  a  primary  cause  for  acute  dilatation,  although  when 
the  stomach  is  dilated  the  enlargement  of  the  organ  tends  to  push 
the  intestines  downward  and  to  create  a  mesenteric  pull  that  is  quite 
enough  to  keep  up  an  obstruction  after  it  has  been  once  started.  This 
view  implies,  therefore,  that  in  the  very  great  majority  of  instances 
mesenteric  constriction  is  a  secondary  factor  in  the  production  of  an 
acute  dilatation. 

4.  The  same  may  be  said  of  mechanical  obstruction  of  the  duodenum 
by  the  pressure  of  an  overloaded  stomach  on  the  duodenum;  in  the 
majority  of  instances  the  dilatation  is  the  first  event  and  the  mechanical 
pressure  of  the  stomach  is  entirely  a  secondary  afl^air. 

5.  Diminished  motor  innervation  by  paresis  of  the  vagus  is  a  plausible 
reason  to  explain  the  occurrence  of  acute  dilatation  following  head 
injuries. 

1  .Johns  Hopkins  Hos]).  Bull.,  January,  1900,  p.  16. 


340  ACUTE  DILATATION  OF  THE  STOMACH 

6.  Lowered  tone  of  the  vomiting  centres  after  anesthesia  as  a  cause, 
may  be  considered  doubtfuh 

7.  Dilatation  of  the  stomach  may  be  increased  after  the  process  has 
once  started,  by  closure  of  the  cardia  either  by  valve-like  folds  of  mucous 
membrane  or  by  lateral  intragastric  pressure  on  an  oblique  insertion 
of  the  esophagus. 

8.  Probably  the  most  potent  cause  for  acute  dilatation  is  a  paralytic 
relaxation  of  the  gastric  wall  due  to  the  effect  of  various  toxins,  in 
infectious  diseases  and  in  septic  conditions.  A  primary  dilatation  so 
induced  may  lead  to  a  certain  degree  of  mesenteric  constriction  which 
is  often  a  marked  contributory  factor. 

9.  Local  peritonitis  of  the  gastric  serosa  with  muscular  relaxation 
may  occur  after  abdominal  operations,  not  sufficiently  intense  to  cause 
septic  or  frank  inflammatory  symptoms  but  quite  sufficient  to  induce 
an  appreciable  degree  of  dilatation  which  may  be  further  increased 
should  any  of  the  secondary  factors  for  dilatation  be  brought  into  play. 

Etiology. — The  various  exciting  causes  for  a,cute  dilatation  may  be 
inferred  from  what  has  been  already  written  concerning  the  modes  of 
origin  of  the  complaint. 

Of  217  cases  compiled  by  Laffer,  97  (44.7  per  cent.)  followed  an  opera- 
tion which  in  60  instances  was  a  laparotomy.  The  occurrence  was  most 
frequent  after  operations  on  the  biliary  system  (15  cases).  Next  in 
frequency  came  operations  of  the  kidney  (1 1  cases)  and  of  the  appendix 
(5  cases).    In  but  4  cases  did  it  follow  operations  in  the  stomach  itself. 

Li  11  instances  dilatation  followed  various  operations  on  the 
extremities. 

The  time  of  onset  after  operation  is  difficult  to  determine,  as  the 
actual  onset  may  be  masked  by  postanesthetic  vomiting.  Li  less  than 
one-half  the  cases  the  symptoms  were  apparent  on  the  first  day  of  the 
operation,  although  the  third  and  fourth  day  furnished  the  larger 
number. 

Tranmaiism  has  been  thought  to  be  a  cause  in  17  cases  in  Laffer's 
series,  })ut  of  these  only  in  5  instances  was  the  force  applied  to  the 
abdomen. 

The  occurrence  of  dilatation  in  orthopedic  patients  after  the  applica- 
tion of  a  plaster  jacket  occurred  in  5  instances. 

A  certain  degree  of  atony  regularly  follows  anesthesia,  the  lower 
curvature  of  the  stomach  extending  below  the  line  of  the  umbilicus. 
Such  an  atonic  condition  should  subside  in  twenty-four  hours,  but 
occasionally  it  may  continue  and  produce  characteristic  symptoms 
of  acute  dilatation,  especially  on  the  third  or  fourth  day,  when  the 
patient  begins  to  take  solid   food. 

Excessive  eating  or  drinking  was  an  alleged  caus(>  in  20  of  Laffer's 


SYMPTOMS  341 

series.  The  dilatation  has  occurred  in  three  instances  after  a  seidHtz 
powder  had  been  given  by  the  physician  to  distend  tlie  stomach  for 
the  purposes  of  examination. 

An  increasing  number  of  cases  are  l)eing  reported  in  which  dilatation 
complicates  the  progress  of  some  infectious  disease  or  septic  process. 
Pneumonia  seems  to  head  the  list,  localized  or  disseminated  tuberculosis 
comes  next  in  frequency.  By  far  the  greater  majority  of  cases  of  acute 
dilatation  give  such  an  antecedent  history  of  disease.  As  earlier  and 
milder  forms  of  the  disease  are  now  recognized,  this  complication  is  not 
as  infrequent  as  we  have  been  led  to  suppose. 

Symptoms. — The  characteristic  symptoms  are  the  repeated  vomiting 
of  copious  bile-stained  fluid  and  a  demonstrable  inflation  of  the  stomach. 

Vomiting  is  usually  the  first  indication  of  the  disease  and  is  present 
in  90  per  cent,  of  the  cases.  Very  characteristic  of  dilatation  in  post- 
operative cases  is  the  vomiting  of  bilious  fluid  at  a  time  when  post- 
anesthetic vomiting  should  have  ceased.  The  few-  patients  who  do 
not  vomit  suffer  the  most  distress,  as  the  organ  becomes  more  rapidly 
overdistended  and  the  true  condition  is  more  readily  overlooked. 
The  vomited  matters  consist  of  a  dark  green  or  black  flocculent  fluid, 
either  odorless  or  foul.  In  rarer  instances,  especially  in  the  cases  com- 
plicating pneumonia,  the  odor  may  be  distinctly  fecal.  The  quantity 
raised  by  any  one  attack  of  emesis  may  not  be  large,  but  the  vomiting 
is  so  incessant  and  uncontrollable  that  the  total  quantity  of  fluid  lost 
becomes  quite  rapidly  excessive,  the  patient  vomiting  "basinfuls" 
during  the  day  or  night.  The  act  of  vomiting  is  rarely  accompanied 
by  much  straining,  but  the  fluid  w^ells  up  in  large  gulps  without  much 
effort.  In  rarer  instances  it  may  be  projectile.  The  vomiting  may  be 
continuous  or  may  disappear  for  hours,  or  even  for  several  days.  The 
cessation  of  vomiting  is  not  to  be  regarded  as  a  favorable  sign  unless 
an  improvement  is  also  noted  in  the  patient's  general  condition  and 
unless  physical  examination  shows  a  marked  diminution  in  inflation. 
Unless  these  favorable  signs  are  present  cessation  of  vomiting  usually 
indicates  a  diminished  power  of  contraction  of  the  stomach  requisite 
for  the  vomiting  act,  and  implies  an  increasing  accumulation  of  fluid 
within  the  stomach. 

Examination  of  the  vomited  matters  show^  almost  invariably  the 
presence  of  bile  and  of  pancreatic  ferments.  Hydrochloric  acid  may 
be  present  and  may  even  be  in  excessive  amounts,  but,  as  a  rule,  the 
reactions  for  free  hydrochloric  acid  are  absent,  possibly  owing  to 
neutralization  by  the  alkaline  fluids  of  the  duodenum.  Lactic  acid 
is  often  present.  Streptococci  and  other  organisms  are  often  found  in 
the  vomited  matters. 

Pain  is  usually  severe  and  is  proportionate  to  the  degree  of  distention. 


342  ACUTE  DILATATIOX  OF   THE  STOMACH 

Al)(l()iiiiiial  teiulenu'ss  iiiii\'  or  may  not  he  present.  Occasionally  acute 
dilatation  of  the  stomach,  even  though  it  he  extreme,  runs  an  entirely 
painless  course. 

Collapse  with  the  Ilippocratic  facies  usually  a])pears  early  in  the  severe 
cases,  and  the  patient  presents  a  rai)i(lly  developing  picture  of  severe 
illness.  The  tongue  is  dry,  the  pulse  rapid  and  feeble,  the  face  assumes 
a  pinched  expression,  the  temperature  is  apt  to  he  subnormal. 

Thirst  is  excessive  and  cannot  be  assuaged.  Dyspnea  and  embar- 
rassed action  of  the  heart  are  occasioned  by  the  upward  i)ressure  of  the 
dilated  stomach. 

In  less  severe  cases  the  general  condition  may  remain  good  for  a 
considerable  ])eriod  of  time  and  the  ])ulse  may  be  surprisingly  regular 
in  frequency  and  of  good  strength.  This  condition  of  well-being  is 
often  quite  misleading,  so  that  the  physician  may  minimize  the  sig- 
nificance of  the  bilious  vomiting  and  epigastric  distention,  and  under- 
estimate the  danger  until  it  is  too  late,  for  unless  the  condition  be  rec- 
ognized and  ])r()perly  treated  the  collapse  symptoms  are  apt  to  appear 
sometimes  earlier,  sometimes  later,  and  too  often  are  the  precursors  of 
a  fatal  issue. 

In  mild  cases  the  symptoms  while  characteristic  may  l)e  much  less 
marked.  Many  i)ostoperative  cases  complain  on  the  day  after  opera- 
tion of  abdominal  ])ain  and  distention,  and  of  the  re])eate(l  vomiting 
of  bilious  greenish  fluid.  The  stomach  on  examination  is  found  to  be 
moderately  enlarged.  These  symptoms  last  a  few  days,  often  regarded 
merely  as  instances  of  i)rolonged  ])ostanesthetic  vomiting,  and  then 
gradually  subside.  The  postural  treatment  is  usually  followed  in  these 
mild  cases  by  com])lete  disa])pearance  of  symptoms  within  a  few  hours. 

Minor  degrt'cs  of  dilatation  may  occur  during  the  course  of  lobar 
pneumonia,  characterized  only  by  abdominal  distention  and  bilious 
vomiting.  These  are  the  early  symptoms,  and  if  neglected,  severe 
abdominal  distention  may  occur  ra])idly,  associated  with  painless  effort- 
less vomiting  and  collapse. 

Physical  Signs. — Epigastric  distention  is  usually  obvious.  The  infla- 
tion of  the  stomach  is  most  marked  at  first  in  the  left  hypochondrium 
corresi)()nding  to  the  vertical  arm  of  the  distended  organ,  later  the  dis- 
tention spreads  to  the  epigastrium  and  downward  so  that  the  whole 
abdomen  is  visibly  ])r()tul)erant,  occasionally  in  the  postoperative 
cases,  tearing  out  the  stitches  and  allowing  the  wound  to  gape. 

Succussion  sounds  and  splashes  are  usually  distinctly  audible  wluMi 
the  stomach  is  shari)ly  pali)ate(l  or  percussed,  and  an  ap])arent  fluctua- 
tion may  even  be  obtained  by  bimanual  palpation. 

\\\  increase  in  |)eristalsis  has  been  \isil)le  in  a  small  number  of  the 
patients  that   were  said   to  be  snllVring  from   acute  (hlatation   of  the 


I'ROdNOSis  343 

stoiiuich.  It  is  u  question  whether  iu  aeute  (hhitatioii  increased  peris- 
talsis in  any  form  can  be  demonstrated  unless  the  acute  dilatation  be 
engrafted  upon  a  more  chronic  obstruction  of  the  pyloric  canal  or 
duodenum. 

Rigidity  of  the  abdominal  muscles  does  not  occur  as  in  peritonitis. 

Diagnosis. — The  diagnosis  is  most  readily  made  by  the  passage  of  a 
stomach-tube.  The  escape  of  air  in  large  quantities,  the  outflow  of 
a  fluid  having  the  characteristic  previously  described,  and  the  flatten- 
ing of  the  epigastrium  after  the  stomach  has  been  thus  emptied  of  its 
gaseous  and  fluid  contents,  are  signs  of  the  greatest  diagnostic  signifi- 
cance, especially  in  the  cases  which  have  not  imdergone  a  previous 
operation. 

The  diagnosis  of  postoperative  dilatation  from  postoperative  ileus 
high  up  in  the  alimentary  tract  due  to  -adhesions  or  kinks  is  often 
impossible,  except  by  the  course  of  the  disease  and  the  improve- 
ment which  may  follow  postural  treatment  and  lavage  in  the  case  of 
gastric  dilatation.  If  the  fluid  withdrawn  from  the  stomach  by  the 
tube  clearly  indicate  its  origin  in  the  small  intestine  the  diagnosis  would 
naturally  incline  toward  intestinal  obstruction.  The  more  pronounced 
the  fecal  odor  of  the  vomitus  the  greater  the  chances  of  actual  obstruc- 
tion. Intestinal  obstruction  high  up  in  the  alimentary  tract  may  present 
symptoms  so  closely  resembling  those  of  acute  gastric  dilatation  that 
a  differential  diagnosis  is  well-nigh  impossible. 

In  certain  instances  chronic  obstruction  suddenly  becomes  acute 
and  complete.  In  these  cases  the  patient  usually  gives  an  antecedent 
histor}'  of  crampy  pains,  recurring  attacks  of  abdominal  distention  and 
vomiting  and  other  signs  which  may  be  indicative  of  neoplasm  or  ulcer. 

General  intestinal  distention  not  due  to  obstruction  or  peritonitis, 
general  peritonitis,  pancreatic  cysts,  uremia,  are  conditions  from  which 
gastric  dilatation  should  be  diagnosticated.  In  most  of  these  conditions 
the  passage  of  a  tube  will  not  afford  relief  as  it  does  in  acute  gastric 
dilatation,  while  in  uremia  there  is  no  distention. 

Prognosis. — Prognosis  is  always  grave.  In  the  earlier  reported  cases 
mortality  exceeded  70  per  cent.  Of  Laffan's  series  62.5  per  cent,  died, 
but  more  recently  under  improved  methods  of  treatment  the  mortality 
has  decreased  to  53  per  cent.  (Payer).  Of  11  cases  of  acute  dilatation 
complicating  pneumonia,  reported  by  Fussell,  5  recovered,  6  died. 
In  the  series  from  which  these  statistics  were  compiled  the  symptoms 
of  the  disease  were  severe  so  that  the  diagnosis  was  evident.  ^Milder 
cases  which  are  now  frequently  recognized  were  not  included.  It  is 
probable  that  as  the  conditions  become  better  recognized  and  the 
therapeutic  indications  more  widely  known  that  the  disease  will  cease 
to  be  as  formidable  as  it  is  now  regarded. 


344  ACl'TE  DILATATION  OF  THE  STOMACH 

Treatment. — The  treatment  of  acute  dilatation  seems  to  be  now 
based  on  correct  principles,  and  if  the  chsease  is  recognized  sufficiently 
early,  medical  treatment  is  often  followed  by  extremely  brilliant  results. 
It  is  to  be  expected,  moreover,  that  by  an  early  and  rigid  enforcement 
of  these  medical  principles  of  treatment  the  mortality  of  the  disease 
will  be  very  considerably  lessened.  The  treatment  is  to  be  conducted 
on  three  principles. 

1.  To  interdict  all  food  and  nourishment. 

2.  To  wash  the  stomach. 

3.  To  cause  the  patient  to  lie  in  such  a  position  that  the  mechanical 
weight  of  the  stomach  and  the  direct  efi'ect  of  mesenteric  traction  are 
overcome. 

1.  All  fluids  and  nourishment  of  any  kind  by  mouth  should  be  abso- 
lutely interdicted.  There  is  no  use  in  adding  to  the  fluid  contents  of 
the  stomach  when  the  presence  of  the  fluid  contents  is  doing  harm, 
and,  moreover,  there  is  very  little  chance  indeed  that  any  fluid  or  food 
given  by  mouth  can  pass  into  the  intestines  and  become  absorbed. 

2.  The  stomach-tube  should  be  passed  at  frequent  intervals  and  the 
stomach  emptied  either  by  aspiration  or  lavage.  The  tube  should  be 
passed  far  enough  to  reach  the  level  of  the  fluid  in  the  stomach,  and  it 
is  well  to  make  a  mental  calculation  that  the  tube  should  be  passed 
far  enough  to  reach  nearly  to  the  pelvis.  An  attempt  to  wash  or  empty 
the  stomach  should  be  made  even  though  the  patient  be  apparently 
moribund.  Collapse  is  no  contraindication,  nor  should  one  hesitate  even 
in  the  presence  of  extensive  and  presumably  fatal  pneumonia.  It  may 
be  urged  that  there  is  no  apparent  reason  for  emptying  the  stomach 
in  eases  of  repeated  and  copious  vomiting,  on  the  ground  that  the 
stomach  is  by  emesis  sufficiently  emptying  itself.  This  argument  is 
entirely  erroneous,  because  the  passage  of  a  tube  even  after  emesis 
will  show  that  a  great  deal  of  fluid  still  remains  in  the  stomach,  the 
patient  only  vomiting  the  surplus.  Lavage  should  be  frequently  per- 
formed, in  severe  cases  even  every  two  and  three  hours,  in  less  severe 
cases  two  and  three  times  a  day.  One  is  guided  as  to  the  frequency 
of  lavage  by  tlic  (juantity  of  fluid  obtained  at  every  procedure  and  upon 
the  apparent  relief  aiVorded,  as  shown  by  the  increased  comfort  evinced 
by  the  patient  and  by  an  improvement  in  his  general  condition.  After 
la\age  the  epigastrium  usually  flattens  itself,  and  an  indication  for  the 
repetition  of  the  procedure  is  the  return  of  epigastric  distention.  Con- 
tinuous drainage  has  been  recommended  l)\  tiie  ])assage  of  a  soft,  rather 
small  tube  through  the  nostril  into  the  stomach  and  retained  in  place 
by  tape  and  adhesive  plaster.  The  fluid  can  be  started  by  compression 
of  a  bulb  inserted  in  the  rubber  tube  of  the  apparatus,  and  siphonage 
so  started  can  be  successfulh'  contiiuicd  for  a  number  of  hours.     The 


TREATMENT  345 

writer  sees  no  advantage  in  continuons  drainage,  liut  ])refers  the  ordinary 
method  of  lavage  frequently  repeated. 

3.  The  postural  treatment  is  of  the  utmost  importance,  and  is  designed 
to  relieve  mesenteric  traction  and  the  weight  of  the  superincumbent 
overloaded  stomach  upon  the  duodenum.  The  dorsal  decubitus  must 
be  positively  prohibited,  and  the  patient  should  be  forced  to  lie  on  the 
right  side  or  on  the  abdomen.  Improvement  often  follows  the  right- 
sided  or  abdominal  posture  within  a  few  hours  and  the  symptoms  often 
recur  in  an  equally  short  period  if  the  patient  reassume  the  dorsal 
decubitus.  The  knee-chest  position  is  theoretically  the  best  posture 
for  the  relief  of  mechanical  conditions,  but  is  usually  impossible  after 
laparotomies  or  during  the  course  of  severe  pneumonia.  The  lateral 
or  ventral  decubitus  seems  to  be  more  effective  when  the  foot  of  the 
bed  is  raised. 

Medicinal  Treatment. — Drugs  are  of  very  little  service.  Theoretically 
eserine  or  physostigma  should  be  of  service.  Eserine,  gr.  j\p,  may  be 
given  hypodermically  every  two  or  three  hours  and  may  be  recommended 
as  a  routine  measure,  although  not  very  much  is  to  be  expected  from 
its  use. 

Apomorphine  to  empty  the  stomach  by  emesis  has  been  recommended, 
but  this  therapeutic  indication  is  better  met  by  lavage  than  by  the  use 
of  so  depressing  a  drug  as  this. 

There  seems  to  be  no  physiological  indication  for  atropine,  although 
it  has  been  suggested  as  a  drug  that  may  be  of  service.  Colon  irriga- 
tions are  often  of  the  greatest  service  in  supplying  fluid  to  the  system 
and  thus  improving  the  general  condition  of  the  patient  and  mitigating 
to  some  extent  the  torments  of  his  thirst  as  well  as  stimulating  gastro- 
intestinal peristalsis. 

Surgical  treatment  of  acute  dilatation  is  now  considered  inadvisable. 
Gastro-enterostomy  has  been  performed  on  the  ground  that  mesenteric 
obstruction  produces  a  duodenal  stenosis  which  can  only  be  treated 
by  surgical  means,  and  that,  moreover,  gastro-enterostomy  is  a  drain- 
age operation.  The  general  consensus  of  opinion  in  the  present  day  is 
decidedly  against  such  an  operation.  The  only  excuse  for  surgery  is 
in  those  postoperative  cases  in  which  a  differential  diagnosis  between 
acute  dilatation  and  acute  obstruction  by  reason  of  adhesions  and 
kinks  is  impossible  to  be  made.  Under  these  circumstances  unless 
the  conditions  improve  by  lavage  and  the  postural  treatment  it  may 
be  justifiable  to  explore. 


CHAPTER   XII 
PYLORIC  SPASM  AND   PYLORIC  STENOSIS 

Pyloric  Spasm. — Spasmodic  closure  of  the  pylorus  as  a  pure  neurosis 
seldom  if  ever  occurs.  Contraction  of  the  pyloric  sphincter,  or  more 
properly  speaking,  reflex  inhibition  of  pyloric  relaxation,  is  regularly 
secondary  to  or  symptomatic  of  an  irritation  in  its  neighborhood,  either 
on  its  gastric  or  its  duodenal  side,  or  it  may  occur  as  a  protective 
spasm  in  irritative  lesions  of  the  midgut  or  its  derivatives.  Gastric 
and  reflex  causes  are  thus  recognized. 

Etiology, — Gastric  Causes. — Temporary  pylorospasm  may  occur  from 
irritation  of  the  prepyloric  portion  of  the  stomach  by  coarse  undi- 
gested or  improper  food.  The  pyloric  sphincter  is  possessed  normally 
of  a  selective  control  of  the  food  which  it  allows  to  pass.  As  the  result 
of  gross  dietetic  error,  the  pylorus  may  contract  to  prevent  improperly 
digested  or  irritating  masses  of  food  from  passing  into  the  duodenum. 
This  form  of  pylorospasm  is  common  in  the  experience  of  nearly  every- 
one. After  the  oft'ending  meal  has  been  eaten  the  patient  will  complain 
of  pains  and  cramps  in  the  stomach,  followed  by  nausea,  heart-burn, 
and  the  vomiting  of  food  residue  admixed  with  acid  fluid,  often  in 
greater  quantities  apparently  than  the  amount  of  food  recently  ingested . 
The  attack  is  terminated  by  the  emptying  of  the  stomach,  and  no 
further  trouble  is  experienced  unless  dietetic  errors  be  repeated. 

Pylorospasm  with  Ulcer. — Pylorospasm  occurs  with  ulcer,  acute  or 
chronic,  in  the  neighborhood  of  the  orifice,  either  gastric  or  duodenal. 
With  acute  ulcer  or  erosion  the  condition  is  analogous  to  the  spasm 
of  the  anal  sphincter  occasioned  by  fissure  at  that  orifice.  In  acute 
ulcer  the  symptom  of  pylorospasm  may  be  first  evidence  of  disease, 
while  in  other  cases  the  spasm  does  not  occur  until  the  ulcer  symptoms 
are  well  established,  and  may  even  appear  during  the  ulcer  cure.  Pyloro- 
spasm from  acute  nicer  is  characterized  by  acute  hypersecretion.  The 
patient  complains  of  a  lump,  oppression,  or  distress  appearing  after 
meals  which  lasts  more  or  less  continuously  during  the  attack.  Relief 
by  eating  is  slight  and  tcmi)orary.  Comfort  is  often  afforded  for  a 
time  by  alkalies,  although  very  large  doses  are  required.  Nausea  and 
vomiting  commonly  occur,  the  vomited  matters  being  liquid  in  character, 
exceedingly  acid,  and  containing  food  remains  that  have  remained  in 
the   stomach    for   an    abnormal    period.      The   \-()mitus   is   often    of   a 


I'/rioi/xiV  847 

browuisli  color,  due  to  altered  hlood.  in  many  cases  the  most  marked 
distress  occurs  during  the  early  period  of  the  night.  Complete  relief 
comes  only  after  vomiting  or  the  emptying  of  the  stomach  through  a 
tube,  but  the  distress  usually  reappears  after  the  lapse  of  several  hours. 

The  symptoms  of  pyloric  spasm  and  acute  hypersecretion  are  given 
in  greater  detail  under  the  heading  of  Ulcer. 

In  chrunic  ulcer  at  or  near  the  pylorus,  gastric  or  duodenal,  pyloro- 
spasm  may  occur  from  time  to  time,  causing  exacerbations  in  the 
symptoms  of  the  disease.  A  constant  and  definite  amount  of  pyloric 
obstruction  may  be  usually  demonstrated  in  the  course  of  chronic  ulcer 
from  inflammatory  or  cicatricial  thickening  of  the  pylorus,  but  exacer- 
bations of  unusual  severity  are  usually  due  to  recurring  pylorospasm 
which  still  further  diminishes  the  lumen  of  the  pyloric  outlet.  The 
symptoms  so  induced  are  largely  due  to  increase  in  the  hypersecretion. 
Patients  complain  of  an  increase  in  pain,  distress  and  heart-burn,  and 
vomiting  of  food  and  acid  fluid,  the  fluid  vomiting  continuing  even 
though  all  nourishment  by  mouth  be  discontinued. 

The  symptoms  may  continue  for  several  days  and  then  subside,  or 
the  added  obstruction  and  the  vomiting  caused  by  it  may  precipitate 
a  fatal  issue. 

Reflex  Pylorospasm. — Reflex  pylorospasm  may  occur  from  any  irrita- 
tive lesion  in  the  course  of  the  embryological  midgut  or  its  derivative, 
but  is  of  special  frequency  with  lesions  of  the  gall-bladder  and  the 
appendix.  Lesion  of  the  gall-bladder  may  produce  either  a  gastric 
atony  or  a  pyloric  spasm.  The  symptoms  of  atony  have  been  elsewhere 
described.  Pylorospasm  is  recognized  by  pain  and  by  the  phenomena 
that  attend  hypersecretion,  pain,  distress,  acidity,  pyrosis,  and  the 
finding  of  acid  fluid  in  the  fasting  stomach. 

With  cholecystitis  and  cholelithiasis  a  spasm  of  the  entire  stomach 
may  occur  during  the  acme  of  pain,  and  undoubtedly  intensifies  the 
agony.  The  possibility  of  such  an  occurrence  is  proved  by  the  a;-ray 
examination  of  the  stomach  of  a  patient  during  an  attack  of  gallstones 
described  by  Schlesinger.^ 

The  diagnosis  of  cases  presenting  this  symptom  complex  suggests 
ulcer  in  the  neighborhood  of  the  pylorus,  and  our  treatment  may 
be  entirely  misdirected  if  we  fail  to  elicit  the  characteristic  physical 
signs  of  cholecystitis.  Comparative  rigidity  of  the  head  of  the  right 
rectus  and  stiffening  of  the  costal  arch  are  suggestive  of  a  gall-bladder 
origin  of  the  disorder,  and  our  suspicion  is  strengthened  if  local  tender- 
ness be  elicited  over  the  gall-bladder,  or  if  a  palpable  enlargement  be 
found  in  this  situation.    Unfortunately  these  signs,  indicative  of  chole- 

1  Berlin,  klin.  Woch.,  June  24,  1012. 


348  I'YJ.ORIC  SI' ASM   A.\D   PYLOHU'  STENOSIS 

cystitis,  are  not  always  present,  or  they  nia>-  be  present  at  some  times 
and  not  at  others,  so  that  repeated  examinations  may  l)e  necessary 
before  the  diagnosis  can  be  established.  For  further  details  the  reader 
is  referred  to  gall-bladder  dyspepsia,  page  57('). 

PylorospasDi  induced  by  irritative  lesions  in  the  appendix  is  a  common 
form  of  gastric  complaint,  and  has  been  recognized  as  a  clinical  entity 
only  in  the  last  few  years. 

To  Moynihan,  the  JVIayos,  and  Paterson  we  owe  a  debt  of  gratitude 
for  their  contributions  on  this  subject.  The  symptom-complex  which 
they  described  appears  in  literature  of  the  present  day  under  the  title 
of  "Appendix  Dyspepsia."  It  has  been  gradually  recognized  that  in 
many  intractable  cases  of  indigestion  where  a  lesion  of  the  stomach, 
duodenum,  or  gall-bladder  was  supposed  to  exist,  no  structural  altera- 
tion could  be  found  at  the  time  of  operation,  but  on  further  examination 
an  appendix  obviously  diseased  is  found  to  exist,  and  its  removal  is 
followed  by  a  complete  relief  of  all  former  indigestion. 

Moynihan^  noted  that  in  many  of  these  cases  spasm  of  the  pylorus 
was  evident  at  operation,  and  in  1904  described  the  condition  as  follows: 
"On  several  occasions  during  the  last  few  years  I  have  watched  the 
stomach  intently  for  several  minutes,  and  have  seen  the  onset,  and 
acme,  and  the  gradual  relaxation  of  a  spasmodic  muscular  contraction 
in  its  walls.  Quite  gradually  the  stomach  narrows,  and  the  wall  becomes 
thicker  and  almost  white  in  color;  when  taken  between  the  fingers 
the  contracted  area  feels  like  a  solid  tumor.  The  spasm  may  be  so 
marked  as  to  prevent  a  finger  being  invaginated  through  the  segment 
affected." 

When  this  condition  is  seen  it  may  be  predicted  that  a  lesion  will 
V)e  found  in  the  appendix.  The  pylorus,  therefore,  acts  as  a  guard  to 
the  bowel  distal  to  it,  and  prevents  the  passage  into  the  duodenum  of 
food  that  might  still  further  irritate  the  bowel  condition.  For  further 
details  of  the  symptoms  of  appendicular  dyspepsia  see  page  5()<S. 

Treatment. — In  acute  pyloric  spasm  due  to  dietetic  error  the  chief 
therapeutic  indication  is  to  empty  the  stomach  of  its  contents,  either 
by  emesis  or  by  washing  of  the  stomach.  Hot  applications  over 
the  epigastrium  are  usually  grateful  to  the  patient.  After  such  an 
attack  the  stomach  should  be  gi\'en  a  rest  by  withholding  food  for 
some  hours. 

When  pylorosi)asm  occurs  in  the  course  of  acute  ulcer,  we  have  not 
only  to  control  the  muscular  spasm  but  to  remove  or  neutralize  the 
excessive  amount  of  acid  fluid  which  is  the  result  of  hypersecretion. 
If  the  patient  l)e  used  to  the  tube  the  stomach  may  be  drained  of  its 

'  Hiilish  Med.  .lour.,  l't()4,  i,  414. 


PYLORIC  STENOSIS  M9 

irritating  contents  l)y  ordinary  aspiration,  or  by  washing  out  tlie  stomach 
with  an  alkaline  solution.  Unless,  however,  experience  has  shown  that 
the  passage  of  the  tube  is  easy  in  a  given  case,  the  tube  should  not  be 
passed,  but  alkalies  should  be  given  in  sufficient  doses  to  neutralize 
the  acid  fluid  and  to  diminish  the  gastric  distress,  No  food  or  drink 
should  be  allowed  by  mouth.  Hot  applications  over  the  epigastrium 
are  of  the  greatest  service  in  reducing  the  spasm  and  afford  relief  to 
the  patient.  Atropine,  hypodermically  administered,  should  be  given 
in  small  repeated  doses  until  the  point  of  physiological  tolerance  is 
reached.  Doses  of  gr.  ^^^  may  thus  be  given  every  three  hours  until 
its  effects  are  evident. 

In  chronic  ulcer  a  complicating  pylorospasm  should  be  controlled 
by  placing  the  patient  during  the  exacerbation  of  his  ailment  upon  a 
liquid  or  semiliquid  diet,  such  as  that  given  during  the  second  week 
of  the  von  Leube  ulcer  treatment.  Alkalies  should  be  administered 
in  sufficient  doses  to  relieve  the  acidity  and  the  distress.  The  atropine 
treatment  may  be  employed.  In  some  of  these  cases  the  oil  treatment 
may  be  followed  by  considerable  improvement.  A  tablespoonful  of 
olive  oil  or  liquid  paraffin,  or  a  3  per  cent,  solution  of  anesthesin  in 
oil,  may  be  given  a  quarter  of  an  hour  before  eating.  In  other  cases  a 
wineglassful  of  oil  may  be  taken  at  bedtime.  The  patient  should  prefer- 
ably be  kept  in  bed  until  the  severity  of  the  attack  be  passed,  and  hot 
applications  over  the  epigastrium  should  be  continuously  applied  unless 
the  patient  has  recently  suffered  from  an  attack  of  hematemesis. 

For  pylorospasm  dependent  upon  gall-bladder  affections,  the  above 
lines  of  treatment  may  be  carried  out  with  the  addition  of  Carlsbad 
water,  of  urotropin,  gr.  7^  in  a  glass  of  hot  water,  half  an  hour  before 
eating,  or  hot  draughts  containing  10  gr.  of  sodium  salicylate  before 
meals. 

For  pylorospasm  of  appendicular  origin  operation  is  indicated. 

No  operation  done  for  the  relief  of  intractable  dyspepsia  symptoms 
referred  to  the  upper  abdomen  is  complete  without  examination  of 
the  appendix  and  its  removal  if  obvious  signs  of  disease  be  present. 


PYLORIC    STENOSIS 

Mechanism. — The  mechanism  of  gastric  digestion  is  so  admirably 
poised  that  the  muscular  power  of  the  stomach  is  sufficient  to  force 
the  digested  food  at  the  projjer  time  into  the  duodenum.  Under  normal 
conditions,  peristaltic  waves  run  continuously  over  the  stomach,  forcing 
the  contents  toward  the  outlet  as  long  as  the  organ  contains  any  food. 
The  discharge  From  the  stomac-h  through  the  pylorus  is  not,  however. 


350  PYLORIC  SPASM  AND  PYLORIC  STENOSIS 

steady,  but  intermittent,  as  it  takes  place  only  when  the  appearance 
of  acid  chyme  in  the  pyloric  antrum  causes  the  sphincter  to  relax. 
When  the  pyloric  sphincter  is  unable  to  dilate  to  its  full  extent,  by 
reason  of  spasm  or  cicatricial  contraction,  or  of  infiltration  of  its  wall 
by  inflammatory  or  neoplastic  tissue,  the  resistance  to  the  onward 
passage  of  chyme  is  necessarily  increased.  An  additional  resistance 
is  encountered  whenever  actual  constriction  or  closure  of  the  outlet 
occurs  by  the  narrowing  of  the  orifice  often  to  such  an  extent  as  to 
barely  permit  the  passage  of  a  slate-pencil.  If  the  contraction  be  slight 
and  not  too  rapidly  progressive,  the  resistance  to  which  it  gives  rise 
may  be  overcome,  either  by  forcible  contraction  of  the  stomach  wall, 
or  by  hypertrophy  of  the  muscular  tissue.  The  increased  resistance  in 
front  is  compensated  by  an  increased  force  from  behind,  so  that  the 
required  amount  of  work  is  accomplished.  This  compensatory  balance 
is  analogous  to  the  hypertrophy  of  the  left  ventricle  of  the  heart,  with 
stenosis  at  the  aortic  orifice.  Should,  however,  the  resistance  in  front 
be  too  great  to  be  overcome  by  an  increase  of  gastric  peristalsis,  or  by 
sufficient  hypertrophy  of  the  muscular  tissue,  the  motor  function  of  the 
stomach  becomes  impaired  and  the  organ  can  no  longer  empty  itself 
in  the  interval  between  the  meals  as  it  should. 

Die  one  characteristic  and  pathognomonic  sign  of  pyloric  steiiosis  is, 
therefore,  the  finding  of  food  remains  in  the  stomach  at  a  time  when  that 
organ  should  normally  he  empty.  This  is  the  one  and  only  infaUihJc  sign 
and  symptom  of  pyloric  stenosis. 

Two  resulting  conditions  must  be  considered. 

1 .  As  a  result  of  food  retention  and  the  stimulation  of  the  secretory 
nerve  apparatus  by  the  peptone  bodies  of  digestion,  as  has  been  so 
admirably  demonstrated  by  Pawlow  and  his  school,  there  regularly 
occurs  a  secretion  of  gastric  juice,  continuous  in  the  sense  that  it  is 
l)oured  out  in  excess  of  the  quantity  required,  as  long  as  there  is  any 
food  lying  in  the  stomach.  This  hypersecretion  adds  greatly  to  the 
bulk  of  the  gastric  contents,  produces  a  symptom  complex  of  its  own, 
and  gives  to  the  vomited  matters  and  test  breakfast  a  fluid  consistence 
that  is  quite  characteristic. 

2.  As  long  as  the  stomach  can  empty  itself  of  the  greater  ])art  of  its 
contents  within  a  reasonable  time,  there  is  room  within  the  stomach 
for  the  small  acc\nnulation  of  residual  food  and  sur])lus  gastric  juice, 
together  with  the  nourishment  and  fluids  taken  at  the  regular  meals. 
When,  however,  the  residual  contents  become  excessive,  the  mechanical 
cfi'ects  of  excessive  bulk  and  weight  begin  to  be  evident,  the  stomach 
loses  its  power  of  resilience,  its  walls  become  stretched  and  flabby, 
and  there  is  a  dilatation  of  the  organ  commensurate  with  the  extra 
burden  which  it  has  to  carrv. 


rVLOUIC  STENOSIS  '.^o\ 

The  word  "dilatation"  in  this  sense  requires  a  word  of  explanation. 
The  term  is  usually  applied  to  all  large  flabby  stomachs  irrespective 
of  their  actual  motor  power.  There  are  large,  bagg\'  stomachs  which 
expel  their  contents  within  proper  time  limits,  and  there  are  normal- 
sized  stomachs  which  are  unable  to  empty  themselves  as  they  should. 
The  size  of  the  stomach  has  nothing  whatever  to  do  with  its  motor 
power.  There  are  uvmierous  examples  of  i)yloric  stenosis  with  fofxl 
stagnation  without  any  change  in  the  size  of  the  stomach  from  the 
normal,  and  in  many  cases  of  cancer  of  the  pylorus,  especially  in  those 
of  rapid  development,  dilatation  may  be  absent  throughout  the  entire 
course  of  the  disease. 

Etiology. — Pyloric  stenosis  may  be  divided  into  two  general  groups — 
benign  pyloric  stenosis,  and  the  malignant  form,  of  which  the  type  is 
cancer.    The  various  causes  for  the  two  forms  may  be  thus  tabulated : 

1.  Benign  pyloric  stenosis. 

(a)  External  pressure  or  traction. 

1.  Adhesions. 

2.  Pressure  of  external  tumors. 
(6)  Contraction  of  the  orifice. 

1 .  Cicatrix  from  ulcer. 

2.  Thickening    of    pyloric   M'all    by    connective    tissue, 

tubercle  tissue,  syphilitic  tissue. 

3.  Benign     tumor     formation     in     the     pyloric    canal, 

fibromyoma. 

4.  Blocking  of  the  lumen  by  pediculated  tumors. 

2.  Malignant  pyloric  stenosis. 

Tumors  of  malignant  character,  infiltrating  the  pylorus  or  encroach- 
ing on  the  lumen. 

Benign  Pyloric  Stenosis. — Perigastric  adhesions  may  bind  the  pylorus 
to  the  neighboring  parts  and  interfere  mechanically  with  its  patency. 
Adhesions  between  the  pylorus  and  the  gall-bladder  or  the  under- 
surface  of  the  liver  are  the  most  important.  The  pylorus  is  frequently 
drawn  sharply  upward  to  the  point  of  attachment,  and  acutely  angu- 
lated.  Tumors  in  the  neighborhood  of  the  pylorus  and  enlarged  glands 
in  the  hilum  of  the  liver  may  often  by  direct  pressure  interfere  with 
the  proper  propulsion  of  chyme.  The  most  frequent  examples  of 
extragastric  tumors  causing  pyloric  stenosis  by  reason  of  their  pressure 
are  enlarged  gall-bladders,  heavy  wdth  stones,  which  lie  like  sandbags 
upon  the  pylorus. 

Contraction  of  the  orifice  is  most  commonly  due  to  the  cicatrization 
of  a  healed  or  healing  ulcer  at  the  pylorus.  Not  only  is  the  lumen 
actually  contracted  in  size,  but  the  infiltration  of  the  wall  of  the  pyloric 
canal   by  dense    scar  tissue  renders  relaxation   impossible.     To  this 


352 


PYLORIC  SPASM    AXD   PYLORIC  STE.XOSIS 


organic  stenosis  there  is  often  added  from  time  to  time  a  spasm  of  the 
pyloric  sphincter,  further  diminishing  the  himen  of  the  orifice.  Acute 
inflammatory  tumefaction  may  also  appear  from  acute  exacerbations 
of  the  ulcerative  process,  and  intensify  the  difficulty,  while  adhesions 
binding  the  pylorus  to  neighboring  parts  interfere  with  its  mobility, 
and  cause  kinks  and  bends  which  further  increase  the  mechanical 
obstruction.  It  is  important  to  remember  that  in  the  healing  of  ulcer  any 
or  all  of  these  stenosing  factors  may  he  present  in  combination,  organic 
contraction,  cicatricial  infiltration,  and  perigastric  adhesions  being 
irremediable  by  medical  treatment,  while  spasm  of  the  sphincter  and 
inflammatory  swelling  may  subside  under  appropriate  treatment. 
Herein  lies  the  hope  and  the  despair  of  the  purely  medical  treatment 
of  the  disease. 

Fig.  65 


Benign    pyloric  stenosis  following  ulfor,  from  the  duodenal  side.      (From   Bloodgood's  colleetion  of 
specimens  in  the  Surgical  Pathological  Laboratory  of  the  .lohiis  Hopkins  Hospital.) 


Infiltration  of  the  walls  of  the  pyloric  portion  often  occurs  with 
circumscribed  cirrhosis  of  the  stomach,  with  tuberculous  deposits,  and 
with  syphilitic  lesions  of  the  stomach  either  in  the  form  of  ulcer  with 
infiltrated  base  or  with  gumma  or  with  diffuse  syphilitic  infiltration. 
These  have  been  described  under  their  respective  headings. 

Benign  tumors  having  their  origin  in  this  portion  of  the  stomach 
may  often  occlude  the  orifice,  and  are  elsewhere  described  in  detail. 

It  has  occasionally  happened  that  polypoid  tumors  of  the  stomach 
with  a  sufficient  length  of  pedicle  may  engage  in  the  pyloric  opening, 
forming  a  ball  valve  which  blocks  the  orifice  completely.  Obstruction 
of  the  pylorus  by  foreign  bodies  or  masses  of  hard   vegetable  fibers 


PYLORIC  STEXO.SfS 


353 


or  of  hair  and  by  concretions  due  to  medicines,  such  as  bismuth, 
administered  in  large  quantities  and  o^•er  long  periods  of  time,  has  been 
known  to  occur,  but -the  obstruction  in  these  instances  is  usually  inter- 
mittent, rarely  continuous. 

It  is  well  to  remember  that  changes  in  the  duodenum  may  occur 
similar  to  changes  in  the  pylorus  itself  and  may  be  productive  of 
gastric  dilatation.  This  is  especially  true  of  ulcers  and  cicatrizations 
above  the  ampulla  of  Vater.  Duodenal  stenosis  below  the  ampulla 
may  be  recognized  by  the  constant  presence  of  bile  and  pancreatic 
juice  in  the  fasting  stomach,  a  phenomenon  quite  different  from  the 
analysis  of  stomach  contents  obtained  in  cases  of  obstruction  above 
the  point  at  which  the  bile  and  pancreatic  ducts  enter  the  duodenum. 


Fig.  06 


Adenocarcinoma  of  pyloric  end  of  stomach,  showing  extreme  degree  of  pyloric  stenosis.  Patient 
alive  and  well  three  years  after  exsection.  (From  Bloodgood's  collection  in  the  Surgical  Laboratory 
of  the  Johns  Hopkin.-^  Hospital.) 


Malignant   Pyloric   Stenosis. — Malignant   stenosis  practically   means 
cancer,  as  the  other  form  of  malignancy,  sarcoma,  is  relatively  rare. 
Interference  with    the   motility    of    the    stomach    by   cancer   may   be 
2.3 


354 


PYLORIC  SPASM  AND  PYLORIC  STENOSIS 


due  either  by  implication  of  the  pylorus  itself  by  the  neoplasm  or  by 
extensive  infiltration  and  adhesions  of  the  gastric  wall  cutting  off  normal 
peristalsis  over  a  large  area. 


Fig.  67 


miimit|{iir|iMi|nii|iiiiii 


lli{tlll|llli|lllltiil 


0       INCH 


i  III  ih  t  ii  till  t  hi  I 


I  li  I  I  li  i 


Cross-section  .shcnviiij;  carcinoniatdii.s  stciidsi.s  nf  (lie  px  Inrus.  /',  \cr\-  niurh  stenosetl  pyloric  canal; 
C,  carcinoma  infiltrating  submucosa  and  muscularis;  S,  greatly  thickened  submucosa  with  carcinoma; 
M,  muscularis.     (From  the  Pathological  Museum,  Columbia  University,  New  York.) 


Symptoms. — The  symptoms  of  pyloric  stenosis  may  be  divided  into 
those : 

1.  Due  to  increased  gastric  peristalsis. 

2.  To  the  hypersecretion  which  is  the  result  of  food  retention. 

3.  To  food  stagnation  within  the  stomach. 

4.  To  the  diminished  amount  of  chyme  that  enters  the  bowel  for 
absorption. 

T.  Increased  Peristalsis. — Pain  and  distress  are  the  inevitable  results 
of  an  increased  peristalsis  and  occur  with  greatest  intensity  when  the 
peristalsis  is  most  active.  In  mild  cases  the  patient  will  complain 
of  a  sense  of  fulness  and  discomfort,  usually  occurring  two  or  three 
hours  after  meals,  so  that  the  patient  may  be  reluctant  to  eat  because 
of  the  resulting  distress.  The  discomfort  may  be  mitigated  by  soda, 
but  is  not  completely  relieved,  as  is  the  case  with  ulcer.  Eating  gives 
but  slight  and  temporary  relief,  and  eventnallx-  is  followed  by  an  in- 
crease in  the  distress,  Temporary  but  incomplete  relief  may  also  follow 
the  eructation  of  gas.  In  the  severer  cases  the  distress  amounts  to  an 
actual  pain,  cither  sliarj)  and  cutting  or  cramp-like  in  character.    These 


PYLORIC  STENOSIS  855 

pains  continue  during  the  period  during  which  the  stomach  is  endeavor- 
ing to  force  its  contents  through  the  constricted  outlet.  If  the  stenosis 
be  but  moderate  the  stomach  ma}'  succeed  in  emptying  itself  more  or 
less  completely,  so  that  succeeding  the  period  of  pain,  comes  gradually 
a  period  of  relief,  but  later  as  the  stomach  succeeds  less  frequently 
and  less  completely  in  emptxing  itself  there  may  be  no  interval  during 
which  pains  may  not  appear,  unless  the  stagnant  contents  be  removed 
by  lavage  or  by  vomiting. 

II.  Hypersecretion. — Hypersecretion  occasions  heart-burn  and  eructa- 
tions of  acid  fluid  and  is  described  in  full  detail  under  hypersecretion, 
page  510.  These  symptoms  are  not  in  themselves  significant  of  pyloric 
stenosis  unless  they  appear  when  the  stomach  should  be  empty.  There 
is  no  other  disease  in  which  the  time  at  which  the  examination  is 
made  is  so  important.  Temporary  relief  is  afforded  by  alkalies  taken 
in  sufficient  doses  to  neutralize  the  large  amount  of  acid  fluid  in  the 
stomach,  and  it  is  suspicious  of  obstruction  at  the  pylorus  if  the  patient 
should  wake  at  three  or  four  o'clock  in  the  morning  and  take  large  doses 
of  soda  for  his  relief.  The  distress  from  heart-burn  and  pyrosis  often 
leads  the  patient  to  induce  vomiting,  as  he  finds  that  often  his  physical 
comfort  can  only  be  brought  about  by  emptying  the  stomach  in  this 
way. 

III.  Food  Stagnation. — The  retention  of  food-remains  in  the  stomach 
past  the  normal  time  limit  sooner  or  later  progresses  to  a  stage  in  which 
the  stomach  is  more  or  less  filled  with  the  food  taken  at  one  meal 
before  the  regular  time  for  the  patient  to  eat  again.  The  food  stasis, 
therefore,  becomes  collective  and  accumulative.  The  signs  of  fulness 
and  satiety  induced  by  the  partially  filled  stomach  at  the  time  of  the 
meal  abolishes  the  normal  appetite  and  may  even  create  distaste  or  a 
loathing  for  food.     This  is  especially  so  with  cancer  of  the  pylorus. 

Occasionally  with  benign  forms  of  obstruction  due  to  cicatricial 
ulcer  there  may  be  a  craving  for  food  to  neutralize  the  excessive 
hypersecretion,  but  this  instinctive  desire  to  eat  is  usually  satisfied 
early  in  the  meal. 

Sooner  or  later  vomiting  is  apt  to  occur.  It  may  be  that  before 
spontaneous  vomiting  occurs  the  patient  will  attempt  to  obtain  relief 
by  inducing  emesis,  or  if  scientifically  inclined,  by  washing  the 
stomach.  ]Many  neurasthenics  contract  the  habit  of  emptying  their 
stomachs  upon  the  occasion  of  any  slight  distress,  but  this  is  usually 
done  during  the  period  of  active  digestion.  Those  with  pyloric  stenosis 
are  more  apt  to  induce  emesis  a  longer  period  than  this  after  eating, 
in  the  majority  of  cases  during  the  night  or  the  early  morning.  As  the 
residual  food  increases,  spontaneous  vomiting  finally  occurs  and  presents 
four  characteristics  that  are  quite  diagnostic  of  pyloric  stenosis. 


35()  PYLORIC  SPASM  AND  PYLORIC  STENOSIS 

1.  The  vomited  matters  consist  of  large  quantities  of  food  remains 
and  liquid,  far  greater  in  volume  than  the  amount  of  food  and  liquids 
introduced  into  the  stomach  for  a  long  period  of  time  preceding  the 
emesis.    The  patient  often  wonders  "where  it  all  comes  from." 

2.  As  the  vomiting  represents  the  last  desperate  attempt  of  the  over- 
loaded stomach  to  empty  itself,  it  is  apt  to  occur  some  hours  after  the 
meal,  usually  between  midnight  and  early  morning.  If  it  can  be  demon- 
strated that  the  patient  repeatedly  vomits  food  in  the  morning  before 
breakfast,  not  having  eaten  since  the  meal  on  the  previous  evening, 
pyloric  obstruction  may  be  safely  diagnosticated. 

3.  In  the  vomited  matters  may  be  found  particles  of  food  that  have 
been  eaten  many  hours  or  even  several  days  previous,  that  have  been 
lying  in  the  stomach  for  this  length  of  time.  Food  may  be  recognized 
as  having  been  eaten  by  the  ])atient  days  or  even  weeks  previously. 

4.  The  vomited  matters  are  quite  liquid  in  character  and  gush  out 
without  much  apparent  effort. 

The  appearance  and  composition  of  the  vomited  matters  are  the 
same  as  of  the  contents  of  the  stomach  in  the  fasting  state,  and  will 
be  described  in  detail  under  the  heading  of  Gastric  Analysis. 

It  is  important  to  remember  that  in  certain  cases  \'()miting  does 
not  occur,  and  therefore  that  the  absence  of  this  symi)tom  does  not 
necessarily  throw  out  pyloric  stenosis. 

IV.  Starvation. — The  symptoms  produced  l\v  the  scanty  amount  of 
digested  food  that  can  pass  into  the  bowel  are  largely  those  of  lack 
of  nourishment  and  dryness  of  tissue. 

Loss  of  Weight. — Loss  of  weight  is  pro])ortionate  to  the  degree  of 
stenosis  and  to  the  frequency  and  ])rofuseness  of  the  vomiting,  the  two 
most  important  factors  which  diminish  the  amount  of  nourishment 
entering  the  bowel  for  absorption.  In  advanced  cases  the  patient  may 
l)e  literally  skin  and  bones,  weighing  often  not  more  than  00  to  70 
pounds.  These  are,  however,  extreme  and  neglected  cases,  fortunately 
not  as  common  in  these  days  as  they  were  some  years  ago  when  the 
diagnosis  had  not  been  perfected  and  when  surgery  had  not  reached 
its  present  development.  Acetonemia  is  not  uncommon  in  these 
extreme  cases. 

Coti.stipation. — The  bowels  are  usually  obstinately  constipated,  the 
fecal  masses  being  hard  and  scybalous.  Attacks  of  diarrhea  may  occur 
from  time  to  time  and  are  due  to  the  irritation  of  the  bowel  from  the 
passage  into  them  of  decomposed  stomach  contents.  In  the  liquid 
movements  sarcinie  may  be  occasionally  found.  These  attacks  of 
colicky  diarrhea  may  appear  long  before  there  are  any  gastric  symp- 
toms of  disease,  and  are  not,  as  a  rule,  correctly  diagnosticated,  although 
examination  of  the  fastinir  stoniacli  will  often  rex'cal  the  true  nature  of 


PYLORIC  STENOSIS  357 

the  iiiliiieiit.  This  is  another  example  of  the  importance  of  estimating 
the  function  and  secretions  of  the  stomach  in  all  cas(.'s  of  ohscun; 
intestinal  trouble. 

Decrease  of  Urine. — The  urine  is  diminished  in  proportion  to  the 
lessened  amount  of  intestinal  absorption  and  the  profuseness  of  the 
vomiting.  Usually  the  amount  voided  is  in  the  neighborhood  of  1000 
c.c,  but  in  extreme  cases  the  quantity  may  be  reduced  to  400  c.c. 
The  urine  shows  the  characteristics  of  concentration,  is  rich  in  phos- 
jjhates  and  poor  in  chlorides.  Acetone  and  diacetic  acid  may  be  present 
in  advanced  cases  of  intestinal  starvation.  The  blood  is  concentrated 
and  is  therefore  relatively  rich  in  the  number  of  red  blood  corpuscles 
and  the  percentage  of  hemoglobin.  Thirst  may  be  excessive,  even 
though  the  stomach  be  filled  to  the  cardia,  and  is  not  assuaged  by 
drinking. 

Dryness  of  Tissues. — The  dryness  of  tissues  may  result  in  numbness 
in  the  fingers  and  toes,  muscular  cramps,  especially  in  the  calves  of  the 
legs,  which  may  be  the  precursors  of  gastric  tetany. 

The  constitutional  symptoms  of  benign  stenosis  are  practically 
those  of  slow  starvation.  In  malignant  disease  of  the  pylorus  we  have 
in  addition  the  symptom  complex  that  attends  malignancy  wherever 
situated.  These  symptoms  have  been  described  in  detail  under  the  dis- 
cussion of  cancer  and  need  not  be  here  repeated.  It  is  sufficient  to 
state  in  this  connection  that  general  symptoms  due  to  malignancy, 
if  present,  are  of  the  utmost  diagnostic  value  in  deciding  whether  in  a 
given  case  we  are  dealing  with  a  benign  or  a  malignant  form  of  pyloric 
obstruction. 

Unfortunately  cancer  in  its  operable  stage  may  not  give  the  least 
evidences  of  its  malignant  character,  so  that  in  many  if  not  in  the 
majority  of  instances  the  diagnosis  can  only  be  made  on  indefinite 
but  suspicious  signs,  symptoms,  and  analyses. 

Gastric  Tetany. — In  a  yery  few  cases  of  advanced  stenosis  gastric 
tetany  develops.  The  symptoms  of  this  justly  dreaded  complication 
begin  with  pricking  and  numbness  of  the  hands  followed  by  carpopedal 
spasms.  The  finger  tips  may  be  brought  together  in  the  form  of  a  cone, 
so  that  the  shape  of  the  hand  is  that  assumed  by  obstetricians  in  their 
examinations.  The  attacks  may  last  for  several  hours  and  may  return 
with  increasing  frequency.  At  any  time  these  slight  symptoms  may 
develop  into  classical  convulsions.  Temporary  disturbances  of  intellect, 
lapses  of  memory,  and  disturbances  of  vision  have  been  described. 

Trousseau's  phenomenon  in  tetany  consists  in  precipitating  a  fresh 
attack  by  forcibly  compressing  the  nerves  or  bloodvessels  of  the  extremi- 
ties. Tonic  spasm  of  the  aflfected  extremity  usually  begins  within 
one  or  two  minutes   and   ceases   when   the   pressure   is  withdrawn. 


o58  PYLORIC  SPASM  AND  PYLORIC  STEXOSIS 

Erb's  phenomenon  is  eliaracterized  by  the  increased  irrital)iHty  of 
the  perij)heral  nenes  to  both  faradic  and  i^alvanic  cnrrents,  with  the 
exception  of  the  facial  nerve.  A  minimnni  strength  of  current  pro(hices 
vigorous  muscular  contractions. 

Chvostek's  phenomenon  is  marked  by  an  excessive  muscular  irrita- 
bility to  mechanical  stimulation.  Percussion  with  the  finger  or  hammer 
over  the  nerve  trunks  is  followed  l)y  lightening-like  contractions  of 
the  muscles  innervated  by  the  irritated  nerves.  This  phenomenon 
is  most  clearly  evidenced  by  the  contractions  produced  by  tapping 
o^•er  the  facial  nerve. 

Many  are  the  theories  advanced  to  explain  the  occurrence  of  gastric 
tetany.  Many  of  them,  such  as  Kussmaul's  theory  of  dehydration  of 
tissue,  and  Germain  See's  theory  of  reflex  action  from  stimulation  of 
the  sensory  fibers  of  the  stomach,  have  been  long  since  abandoned. 
Nothing  is  definitely  known  about  its  causation,  although  the  theory 
of  auto-intoxication  from  the  products  of  the  fermenting  stagnating 
gastric  contents  appears  to  be  the  most  reasonable  one  as  yet  advanced. 

Intermittent  or  Latent  Stenosis. — The  course  of  the  disease  may  either 
be  steadily  progressive,  especially  in  the  malignant  cases,  or  it  may 
be  interrupted  by  periods  of  apparent  improvement.  Although  struc- 
tural stenosis  may  remain  unchanged,  varying  conditions  of  tumefac- 
tion and  spasm  of  the  pyloric  sphincter  may  temporarily  increase  the 
mechanical  difficulty  so  that  the  symptoms  become  acutely  aggravated. 
If  the  organic  element  of  the  stenosis,  such  as  the  degree  to  which  it  is 
rendered  impervious  by  cicatricial  contraction,  be  relatively  slight,  so 
that  by  increased  muscular  force  the  obstruction  may  be  overcome, 
such  a  condition  of  compensation  may  not  be  attended  by  stasis,  nor 
by  any  other  characteristic  sign  or  symptom,  although  a  careful  history 
will  usually  elicit  the  fact  that  there  is  often  a  sense  of  fulness  and 
discomfort  following  the  meals  and  occasionally  even  more  severe 
epigastric  pains.  In  this  stage  of  comparative  latency  the  condition 
may  extend  over  months.  These  are  almost  regularly  cases  of  benign 
stenosis,  although  occasionally  even  malignant  pyloric  stenosis  may  run 
such  a  comparatively  quiescent  course. 

From  time  to  time,  either  from  inflammatory  swelling  or  from  pyloric 
sj)asm,  symptoms  of  a  more  definite  character  occur.  The  patient 
will  coin])laii)  of  attacks  of  epigastric  pain,  often  lasting  for  several 
days.  The  attacks  may  follow  gross  errors  in  diet  or  may  follow  periods 
of  intense  mental  or  physical  strain.  The  pain  varies  from  one  that  is 
dull  and  aching  in  character  to  sharp  colicky  paroxysms.  During  the 
acme  of  pain  epigastric  tenderness  is  not  infrequently  extreme.  The 
patient  finds  relief  either  in  inducing  vomiting  or  washing  the  stomach, 
the   contents   so   e\;icuiitcd    being   copious,    watery,    usually    intensely 


PYLORIC  STENOSIS  359 

acid,  and  containing  food  remains  tiiat  have  been  retained  in  tlie  stomach 
long  past  the  normal  time  Hmits,  or  seeks  mitigation  of  the  distress  by 
abstinence  from  all  food  for  twenty-four  to  thirty-six  hours,  thus  allow- 
ing the  overloaded  stomach  to  empty  itself  gradually  in  the  natural 
way  without  further  adding  to  its  burden.  During  the  attack  the  out- 
line of  the  stomach  may  be  distinctly  visible,  gastric  stiffening,  visible 
peristalsis,  and  succussion  sounds  long  after  the  last  meal  may  be 
obtained  on  examination,  and  the  passage  of  the  tube  withdraws  fluid 
and  food  remains  characteristic  of  pyloric  obstruction. 

After  such  an  attack  of  sudden  decompensation  is  over,  conditions 
of  apparently  fair  digestion  are  resumed,  and  the  patient  eats  a  reason- 
able quantity  of  food  with  impunity.  Examinations  of  the  fasting  and 
digesting  stomach  may  show  no  apparent  departures  from  the  normal. 
These  cases  are  often  spoken  of  as  latent  or  intermittent  pyloric  stenosis, 
or  the  stenose  meconne  du  pylore  of  French  writers  (Oettinger) . 
An  interesting  example  of  this  intermittent  course  is  as  follows: 
E.  N.,  aged  seventy  years,  was  well  until  ten  years  ago,  when  he  com- 
plained for  about  a  year  of  pain  in  his  stomach  two  or  three  hours  after 
eating,  lasting  until  he  vomited,  or  ate  again.  He  was  then  free  from 
all  distress  until  fifteen  months  ago,  when  for  a  week  he  had  more  or 
less  constant  epigastric  pain  and  copious  vomiting  of  a  clear  exceedingly 
acid  fluid  which  brought  temporary  relief.  After  this  attack  he  experi- 
enced no  further  trouble  until  three  months  ago,  when  acute  symptoms 
again  appeared.  He  would  feel  comparatively  well  during  the  morning 
and  would  eat  his  accustomed  breakfast  and  lunch.  In  the  middle  of 
the  afternoon  severe  gastric  pains  would  appear  and  would  grow  so 
intense  as  night  approached  so  that  he  was  unable  to  eat  any  dinner. 
Toward  midnight,  when  the  pains  were  well-nigh  unendurable,  he  would 
vomit  with  but  little  eflfort  2  or  3  pints  or  more  of  a  scalding  acid  fluid 
containing  in  suspension  the  greater  part  of  what  he  had  eaten  in  the 
earlier  part  of  the  day.  After  the  stomach  had  been  thus  emptied  he 
would  feel  perfectly  comfortable  and  would  sleep  soundly  throughout 
the  remainder  of  the  night.  After  he  passed  through  such  an  experience 
for  several  successive  nights  his  symptoms  would  disappear  for  possibly 
two  or  three  weeks  before  the  occurrence  of  another  attack. 

In  the  interval  between  attacks,  examination  of  the  fasting  stomach 
showed  the  presence  of  55  c.c.  clear  fluid  wdth  only  a  few  microscopical 
food  remains.  Total  acidity  58,  free  hydrochloric  acid  42.  The 
abstracted  test  breakfast  consisted  of  95  c.c.  of  well-digested  bread- 
stuffs  without  any  trace  of  food  previously  taken.  Total  acidity  78, 
free  hydrochloric  acid,  40. 

The  patient  was  not  seen  for  three  months  after  this,  his  first  examina- 
tion, because  he  felt  perfectly  well  and  considered  his  indigestion  at 


3G0  PYLORIC  ."^PASM  AXD  PYLORIC  STENOSLS 

an  end,  gaining  11  pounds  during  tliis  time  and  eating  everything  he 
wished  without  discomfort.  Suddenly  and  without  warning  the  noctural 
vomiting  reappeared.  Oii  the  third  day  of  his  distress  he  was  seized 
with  intense  abdominal  pain  and  the  attendant  symptoms  of  perfora- 
tion were  quite  e^•ident.  Operation  was  performed  six  hours  after 
the  accident  and  a  perforation  was  found  in  the  base  of  an  old  ulcer 
exactly  at  the  pyloric  juncture.  The  pyloric  ring  was  thickened  by 
cicatricial  tissue  and  would  barely  admit  the  passage  through  it  of  a 
lead-pencil.  The  perforation  was  closed,  gastrojejunostomy  performed, 
and  the  patient  made  an  uninterrupted  recovery. 

In  a  few  instances  pyloric  stenosis  may  exist  even  to  an  extreme 
degree  without  producing  any  symptoms  until  decompensation  suddenly 
occurs.  The  symptoms  of  pyloric  obstruction  appear  suddenly  and  are 
often  so  .severe  as  to  suggest  complete  blocking  at  the  outlet.  The 
symptoms  once  started  in  full  force  do  not  pass  away  after  a  few  days 
as  in  the  former  class  of  intermitting  stenosis,  but  grow  daily  more 
marked,  so  that  the  patient  will  die  within  a  few  days  of  the  onset 
unless  relieved  by  a  timely  operation. 

Such  an  example  of  a  latent  course  with  the  sudden  accession  of 
alarming  symptoms  may  be  briefly  cited. 

K.  J.,  aged  forty-three  years,  was  well  until  two  weeks  ago,  when  she 
began  to  complain  of  a  moderate  heart-burn  two  hours  after  eating, 
relieved  temporarily  by  food,  but  completely  alleviated  by  soda.  Three 
days  ago  without  apparent  cause  she  began  to  vomit  everything  that 
she  ate,  the  vomitus  being  acid,  copious,  and  watery. 

Fasting  stomach  contained  30  c.c.  of  liquid  and  food  remains,  the 
liquid  being  three  times  the  depth  of  the  sediment.  Total  acidity  44, 
free  hydrochloric  acid  16.  Sarcina?  were  present  in  great  profusion 
No  lactic  acid  nor  an}'  blood. 

Test  breakfast  250  c.c,  fairly  well  digested,  three-quarters  of  the 
settled  contents  being  fluid.    Total  acidity  130. 

A  tumor  the  size  of  a  horse-chestnut  was  palpable  in  the  pyloric  area. 

An  immediate  operation  was  performed  by  the  late  Dr.  W.  T.  Bull, 
and  a  thickened  mass  was  found  invading  the  pyloric  region  and  ex- 
tending along  the  lesser  curvature  nearly  to  the  cardia.  The  pylorus 
would  with  difficult}'  admit  a  sound  the  size  of  a  slate-pencil.  The  mass 
was  exsected  on  the  probabilit}-  that  it  was  cancerous,  but  the  patho- 
logical report  was  that  it  consisted  only  of  dense  connective  tissue 
without  any  trace  whatexer  of  malignancy. 

Even  cancer  of  the  pylorus  may  run  such  an  insidious  course  that  it 
may  be  totally  unsu.spected  until  the  sudden  appearance  of  severe 
stenotic  symptoms.  In  one  of  the  writer's  cases  there  were  absolutely 
no  s\'mptoms  whatcxer  of  iinpfiidiiig  disease  until  the  sudden  onset 


PYLORIC  STENOSIS  361 

of  acute  watery  acid  vomitin<>-  which  continued  in  spite  of  abstinence 
from  all  food  and  liquids  by  mouth,  the  daily  quantity  vomited  being 
about  5  i)ints  during  his  starvation  treatment.  Operation  on  the 
third  day  showed  a  carcinoma  the  size  of  a  lemon  at  the  pylorus.  The 
pylorus  would  not  admit  the  passage  of  a  lead-pencil. 

Physical  Signs. — Physical  signs  may  be  totally  lacking  in  mild 
degrees  of  pyloric  obstruction,  even  when  the  examination  of  the 
stomach  shows  an  appreciable  quantity  of  food  residue  in  the  fasting 
state.  In  more  marked  cases  a  variety  of  physical  signs  appear,  the 
most  important  of  which  are  due  to  hypertonus  and  increased  peristalsis 
of  the  stomach  wall. 

1.  Inspection  may  show  the  outline  of  the  lower  curvature  of  the 
stomach  to  be  distinctly  visible,  provided  the  abdominal  wall  is  not 
too  thick.  Inspection  should  be  made  by  a  strong  and  oblique  light, 
and  the  line  of  shadow  is  best  detected  by  standing  behind  the  head  of 
the  patient  as  he  lies  on  the  table  or  couch  for  examination. 

2.  Waves  of  peristalsis  may  be  observed  from  time  to  time  passing 
in  stately  march  over  the  region  of  the  stomach  from  left  to  right  and 
are  most  clearh-  in  evidence  several  hours  after  the  meal  when  the 
stomach  is  endeavoring  to  empty  itself.  The  waves  may  be  slight 
or  they  may  be  gross  enough  to  be  clearly  visible  at  a  distance  of 
two  or  three  yards,  but  feeble  or  vigorous  they  indicate  a  mechanical 
obstruction  to  the  onward  passage  of  food  that  is  being  compensated 
by  more  vigorous  muscular  contractions  from  behind.  Absence  of 
peristalsis  does  not  exclude  pyloric  stenosis,  as  it  may  happen  that 
the  stomach  is  no  longer  able  to  rise  to  the  emergency  by  contractions 
that  are  powerful  enough  to  be  visible.  Such  an  enfeebled  power  may 
be  the  precursor  of  decompensation,  for  in  these  cases  examination 
in  the  fasting  state  usually  shows  a  rapid  increase  in  the  amount  of 
residual  food.  The  most  vigorous  peristalsis  is  seen  with  benign 
stenosis.  In  cancer  the  waves  are  usually  feeble  or  may  even  be  en- 
tirely absent,  unless  the  cancer  be  engrafted  on  an  ulcer  that  has  already 
caused  an  appreciable  degree  of  stenosis.  The  writer  would  regard 
the  relative  vigor  of  peristalsis  as  an  important  means  of  ditt'erentiating 
the  benign  and  the  malignant  forms  of  the  disease,  although  naturally 
too  much  reliance  should  never  be  placed  on  the  presence  of  a  single 
sign  alone. 

3.  Peristalsis  may  be  appreciated  by  palpation  of  the  stomach  area. 
At  the  time  of  vigorous  contraction  the  organ  may  be  distinctly  felt 
as  one  might  feel  an  inflated  air  cushion.  This  so-called  "stomach- 
stiflening"  may  be  more  distinct  at  some  parts  of  the  stomach  than 
at  others,  but  usually  it  is  recognized  without  difficulty,  and  like 
peristaltic   waves   is   a    sign    of   great   diagnostic   significance. 


302  PYLORIC  SPASM   AND   PYLORIC  STENOSIS 

4.  Succussion  sounds  and  splashes  are  .frequently  heard  during  the 
palpation  or  i)ercussion  of  the  stomach,  and  are  not  of  themselves 
significant  of  pyloric  stenosis  except  when  they  are  audible  at  the  time 
in  which  the  stomach  should  be  empty.  Succussion  sounds  readily 
elicited  in  the  stomach  before  breakfast  implies  the  presence  of  fluid 
in  the  fasting  stomach,  which  ordinarily  means  pyloric  stenosis. 

5.  Palpation  of  the  pyloric  region  may  or  may  not  give  evidence  of 
disease.  In  making  a  systematic  palpation  of  the  organ  it  is  generally 
best  to  map  out  the  lower  curvature  and  then  to  palpate  along  this  line 
to  the  right  and  upward,  so  that  the  line  of  examination  leads  directly 
to  the  pylorus. 

The  presence  of  a  tumor  depends: 

(a)  Upon  the  tonicity  of  the  pyloric  sphincter. 

(b)  Upon  the  new  tissue,  cicatricial  or  malignant,  that  is  deposited 
in  or  about  the  pylorus. 

(c)  Upon  the  presence  of  extensive  adhesions. 

In  stenosing  ulcer  that  is  not  accompanied  by  the  deposit  of  great 
amount  of  cicatricial  tissue,  there  may  be  nothing  that  is  palpable 
over  the  pylorus.  Should  spasm  of  the  sphincter,  however,  be  present 
it  may  be  ])ossible  to  feel  the  tonically  contracted  pylorus  as  a  firm, 
short,  cylindrical  body  which  appears  and  disappears  as  the  pylorus 
contracts  and  relaxes.  At  the  time  of  relaxation  a  "  pyloric  squirt"  may 
be  audible  through  the  stethoscope  but  is  not  of  a  diagnostic  significance. 

If  the  new  tissue  about  the  pylorus,  whether  cicatricial,  tubercular, 
syphilitic,  or  carcinomatous,  be  sufficient  to  form  a  mass,  a  tumor 
becomes  palpable,  more  or  less  movable  according  to  whether  or  not 
it  has  become  adherent  to  neighboring  parts.  Tumors  of  sufficient  size 
to  be  distinctly  palpable  under  ordinary  conditions  may  be  so  drawn 
up  under  the  liver  by  adhesions  that  it  is  not  possible  to  detect  them 
by  palpation. 

The  characteristics  of  the  tumor  of  cancer,  ulcer,  and  of  other  forms 
of  pathological  infiltration  are  described  in  full  under  their  respective 
headings. 

6.  To  determine  the  size  of  the  stomach  and  the  degree  to  which 
it  is  dilated,  a  rough  idea  can  be  gained  by  locating  the  lowest  point 
at  which  succussion  sounds  are  heard:  This  is,  however,  a  test  which 
is  inaccurate  in  many  instances.  The  lower  curvature  may  be  mapped 
out  by  inspection  during  the  period  of  gastric  stiffening  or  by  locating 
the  lowest  j)oint  at  which  ])eristaltic  waves  are  visible.  More  accurate 
determinations  are  made  by  inflation,  either  by  a  bulb  attached  to  a 
stomach  tube  or  by  effervescing  powders. 

By  means  of  the  .r-rays  the  size  and  position  of  the  stomach  may  be 
dctcrniincd  with  great  accuracy. 


I'YLORIC  STI'JXOSIS  3(i3 

7.  The  mociianical  \vei<;ht  of  the  staf^iiaiit  contents  tends  to  dis- 
place the  stomach  downward.  If  tlie  jniorus  be  held  up  by  arlhesions 
the  sagf^infi;  is  chiefly  in  the  median  zones  and  is  of  a  sharply  crescentic 
outline,  but  should  the  pylorus  be  freely  movable  the  whole  stomach 
not  only  sags  downward  but  assumes  more  of  an  oblique  position, 
so  that  the  pylorus  may  be  in  the  right  iliac  fossa  and  the  greater 
curvature  cross  just  above  the  pelvic  brim. 

It  is  interesting  but  not  very  important  to  know  the  exact  measure- 
ments of  the  stomach.  The  important  point  to  be  decided  is  whether 
the  stomach  can  do  its  work  and  empty  itself  as  it  should,  and  not  how 
large  the  organ  is  or  how  distensible. 

Diagnosis. — Gastric  Analysis. — The  diagnosis  of  pyloric  obstruction 
ma}'  be  made  with  absolute  certainty  by  gastric  analysis,  while  without 
this  means  of  examination  errors  in  diagnosis  are  apt  to  creep  in.  The 
most  important  examination  by  far  is  that  of  the  fasting  stomach. 
By  the  detection  of  appreciable  amounts  of  fluid  with  or  without  food 
remains  in  the  fasting  state  we  have  conclusive  proof  of  a  mechanical 
obstruction  at  the  pylorus.  To  determine  w^hether  this  obstruction 
be  temporary,  due  to  spasm,  or  permanent,  due  to  structural  change, 
repeated  examinations  may  be  necessary,  and  should  by  preference 
be  made  in  all  cases  in  which  the  disease  is  suspected.  The  amount  of 
food-stasis  and  its  resulting  hypersecretion  vary  from  time  to  time,  so 
that  the  evidence  afforded  by  the  examination  may  be  less  conclusive 
at  one  time  than  at  others.  It  not  infrequently  happens,  especially 
in  malignant  cases,  and  even  though  the  stenosis  is  quite  marked, 
that  the  first  examination  may  not  reveal  sufficient  deviation  from  the 
normal  to  warrant  any  inferences,  but  that  subsequent  examinations 
may  be  such  as  to  clearly  demonstrate  the  presence  of  a  mechanical 
obstruction  of  the  outlet  of  the  stomach.  The  importance,  therefore, 
of  repeated  examinations  cannot  be  too  strongly  emphasized.  Func- 
tional disturbances  of  motility,  such  as  atony,  never  lead  to  constant 
accumulation  of  liquid  or  food  remains  in  the  fasting  state.  Food- 
stasis  from  atony  does  not  occur. 

Gastric  analysis  may  be  identical  in  benign  and  malignant  stenosis, 
while  the  examinations  demonstrate  the  existence  of  a  stenosis  at 
the  outlet  of  the  stomach,  they  may  not  furnish  any  clue  whate\-er 
to  the  exact  nature  of  the  obstruction.  Unfortunately,  this  is  often  the 
case  with  cancer  that  is  still  in  the  operative  stage.  When  gastric 
analysis  points  conclusively  to  a  malignant  origin  for  the  disease,  it  is 
often  too  late  to  expect  much  from  radical  operations.  Nevertheless, 
it  is  convenient  from  a  clinical  standpoint  to  contrast  as  best  we 
may  between  the  analyses  in  benign  cases  and  those  of  malignant 
character. 


364  PYLORIC  SPASM  AND  PYLORIC  STENOSIS 

Method  of  Examination. — The  patient  should  be  (Hrected  to  eat  his 
dinner  or  his  evening  meal  as  usual  the  night  before  the  examination. 
At  10  o'clock  that  night  he  should  be  told  to  eat  a  meat  sandwich  and 
to  drink  a  glass  of  water,  to  which  may  be  added  a  handful  of  raisins 
or  a  tablespoonful  of  dried  currants.  After  this  late  evening  meal  he 
should  take  nothing  by  mouth,  not  even  a  sip  of  water,  until  he  reports 
for  examination  the  following  morning.  Should  vomiting  occur  during 
the  night  the  vomited  matters  should  be  brought  for  examination,  and 
the  time  at  which  the  vomiting  occurred  should  be  noted  on  the  speci- 
men. If  several  attacks  of  vomiting  occur,  the  specimens  should  be 
separately  collected  and  examined. 

After  such  a  test  meal  the  stomach  should  normally  be  empty  the 
following  morning  by  8  or  9  o'clock.  Small  quantities  of  acid  fluid 
luider  ;>()  c.c.  in  volume  may  be  disregarded.  Quantities  of  acid  fluid 
from  30  to  50  c.c.  are  on  the  borderline  between  pyloric  spasm  and 
pyloric  stenosis  of  organic  origin.  Quantities  exceeding  50  c.c.  may 
occur  in  either  conditions,  but  are  rare  with  pyloric  spasm.  The  nearer 
the  quantity  of  fluid  approaches  100  c.c.  the  more  clear  becomes  the 
diagnosis  of  an  organic  obstruction. 

Gastric  Analysis  in  Benign  Stenosis. — Fasting  Stoniach. — The  quantity 
of  supernatant  liquids  is  usually  more  abundant  than  in  the  malignant 
form  and  shows  a  high  acidity  composed  almost  entirely  of  free  and 
combined  hydrochloric  acid.  The  total  acidity  is  almost  always  over  70, 
usuall\'  between  85  and  1 10,  although  it  may  be  as  high  as  120.  Reaction 
for  free  hydrochloic  acid  is  sharp  and  decisive,  and  the  total  amount  of 
the  free  acid  may  l)e  represented  by  an  acidity  not  more  than  20  points 
less  than  the  total  acidity.  It  is,  therefore,  evident  that  the  bulk  of 
the  fluid  is  composed  of  free  hydrochloric  acid,  and  that  the  combined 
acid  is  relatively  less  abundant.  Slight  reactions  for  lactic  acid  may 
occasionally  be  noted,  depending  upon  the  character  of  the  food 
that  has  last  been  ingested,  but  positive  reactions  for  lactic  acid 
in  appreciable  amounts  are  not  encountered  in  cases  of  benign 
stenosis. 

Sarcinte  are  usually  found  and  are  characteristic  of  benign  stenosis, 
as  for  their  development  not  only  does  free  hydrochloric  acid  seem 
necessary,  but  also  a  certain  degree  of  stagnation  of  the  gastric  contents. 
When  stasis  exists  and  when  the  secretion  of  hydrochloric  acid  is  main- 
tained they  are  in  their  greatest  development.  When  free  hydrochloric 
acid  fails,  their  growth  may  be  maintained  for  a  time  at  least  by  the 
loosely  combined  hydrochloric  acid  that  may  be  present,  but  if  after 
total  disapj)earance  of  both  free  and  combined  hydrochloric  acid, 
lactic  acid  formation  gradually  takes  place,  sarciuie  find  the  conditions 
hostile  to  tlicir  dcxclopnicnt  and  begin  to  disai)])('ar. 


PYLORIC  ST  EN  OS  LS 

Fig.  G8 


365 


Fasting  contents  in  pyloric  stenosis  due  to  cicatrizing  ulcer  of  the  pylorus  taken  ten  hours  af(er 
the  previous  meal.  Hypersecretion  is  here  well  demonstrated.  Total  acidity,  96;  free  hydrocliloiic 
acid,  74;  no  lactic  acid;  sarcinse  present;  no  Oppler-Boas  bacilli;  blood  positive. 

Fig.  69 


Fasting  contents  of  benign  pyloric  obstruction  ten  hours  after  the  previous  meal. 
SO;  free  hydrochloric  acid,  6S;  no  lactic  acid. 


Total  acidity, 


366  PYLORIC  SPASM  AND  PYLORIC  STENOSIS 

A  few  sarciiiae,  according  to  Boas,  may  be  found  in  the  gastric  con- 
tents of  healthy  persons,  without  being  of  diagnostic  importance;  it 
is  only  when  numberless  packets  are  seen  in  every  field  of  vision  that 
they  are  indicative  of  motor  insufficiency  of  high  degree.  The  writer 
has  not  as  yet  found  sarcinae  in  the  contents  of  a  normal  stomach. 

Sarcinse  are  often  present  in  the  stools  of  those  suffering  from  pyloric 
stenosis,  especially  in  the  evacuations  of  the  gastrogenetic  diarrhea 
that  may  complicate  this  disease.     They  are  occasionally  bile-tinged. 

Yeast  cells  are  often  seen  in  abundance  and  show  a  proclivity  toward 
the  budding  forms.  Too  much  importance  must  not  be  placed  on  the 
finding  of  yeast,  even  of  the  budding  forms,  in  the  fasting  stomach, 
as  they  may  be  found  in  apparently  normal  conditions. 

Lactic  acid  and  lactic  acid  bacilli  are  rarely  found  with  the  purely 
benign  forms  of  pyloric  stenosis  and  suggest  malignancy. 

Fermentation  processes  are  less  active  in  the  benign  forms  than  in 
the  malignant,  probably  owing  to  the  antifermentative  power  of  the 
gastric  juice,  so  that  while  organic  acid  may  be  present  the  quantity 
is  rarely  sufficient  to  give  a  characteristic  odor  to  the  contents.  Car- 
bohydrates if  retained  too  long  within  the  stomach  may  undergo 
decomposition,  producing  carbon  dioxide,  hydrogen,  marsh  gas,  oil- 
forming  gas,  and  other  gases  of  fermentation,  some  of  which  are  inflam- 
mable. The  production  of  these  gases  is  not  inhibited  by  the  presence 
even  of  large  amounts  of  hydrochloric  acid.  The  mechanical  obstruc- 
tion to  the  digestion  is  the  chief  cause  for  the  fermentation;  the  presence 
or  absence  of  hydrochloric  acid  is  of  inferior  importance. 

Decomposition  of  the  albumin  may  later  take  place  in  the  ectatic 
stomach,  even  in  the  presence  of  free  hydrochloric  acid,  and  one  of  its 
products,  sulphuretted  hydrogen,  can  be  readily  detected. 

Three  grades  of  severity  of  the  disease  may  be  recognized,  according 
to  the  gross  appearance  of  the  fasting  contents. 

In  the  mild  form  we  find  a  fluid  of  clear  or  slightly  opalescent  appear- 
ance, which  on  standing  shows  a  slight  sediment,  the  constituents  of 
which  cannot  be  determined  by  the  naked  eye,  but  which  usually  under 
the  microscope  prove  to  be  finely  digested  food  remains,  usually  of  the 
carbohydrate  group  of  foods.  The  quantity  varies  from  'M)  to  40  c.c. 
to  KM)  or  even  120  c.c.  This  mild  form  is  usually  described  as  chronic 
hypersecretion  or  Reichmann's  disease. 

In  the  severer  cases  we  have  a  ditt'erence  in  degree  only.  The  quantity 
of  fluid  is  somewhat  more  abundant,  the  sedimentary  layer  more  clearly 
defined,  and  it  becomes  evident  to  the  naked  eye  that  the  sediment 
is  composed  of  food  remains  distinctly  to  be  recognized  as  such.  In 
these  milder  cases  fermentative  changes  are  rarely  present. 

Ill  the  most  s('\er('  cases  the  (|Uiiiitit\-  taken  from  the  fasting  stomach 


PYLOlilC  STENOSIS  367 

is  strikingly  copious  and  may  even  amount  to  one  or  more  liters.  In 
one  of  the  writer's  cases  11  pints  of  fluid  and  of  food  remains  were 
withdrawn  on  one  examination. 

On  standing,  three  layers  are  more  or  less  clearly  defined.  The  lowest 
consists  of  food  remains  of  recent  or  of  ancient  date,  more  or  less  per- 
fectly digested,  and  often  fermenting.  The  depth  of  this  sedimentary 
layer  represents  the  actual  amount  of  permanent  food-stasis. 

The  middle  layer  consists  of  slightly  turbid  or  ()i)alescent  fluid, 
varying  in  amount  according  to  the  degree  of  the  hypersecretion.  The 
fluid  layer  may  be  brownish  from  altered  blood,  or  in  exceptional  in- 
stances may  be  bile-tinged.  Bile  may  thus  be  present  even  with  demon- 
strable stenosis  of  the  pylorus  in  cases  of  infiltration  of  the  pyloric 
wall  which  lead  to  a  "rigid  patency"  of  the  outlet.  When  such  a  con- 
dition occurs,  the  pyloric  sphincter  may  be  unable  to  relax  sufficiently 
for  the  normal  passage  of  chyme  through  it,  and  at  the  same  time  be 
quite  unable  to  contract  and  prevent  the  regurgitation  of  bile,  especially 
if  straining  efforts  be  made  by  the  patient  during  the  passage  of  the 
tube. 

The  upper  layer  is  of  comparatively  shallow  depth  and  consists  of 
mucus,  swallowed  saliva,  and  pharyngeal  secretions  intermixed  with 
gross  particles  of  food  that  are  light  enough  to  float,  often  frothy 
from  gases  of  fermentation. 

In  the  milder  cases,  when  the  bulk  of  the  contents  consists  chiefly  of 
surplus  gastric  juice,  no  abnormal  odor  may  be  detected.  When  food- 
stasis  is  more  pronounced  the  odor  may  be  sour,  yeasty  or  rancid  accord- 
ing to  the  amount  of  organic  acids  generated  by  fermentation. 

Sulphuretted  hydrogen  may  be  detected  in  both  benign  and  malignant 
stenosis,  but  is  more  common  with  the  latter  group.  The  presence  of  the 
gas  may  be  easily  demonstrated  by  any  of  the  chemical  tests.  A  simple 
test  is  to  place  the  contents  in  a  tightly  corked  bottle,  in  which  pieces  of 
filter  paper  moistened  by  a  solution  of  lead  acetate  and  caustic  potash 
are  suspended  from  the  cork.  Odors  that  are  foul  or  putrid  suggest 
ulcerating  neplasms. 

Test  Breakfast  in  Benign  Stenosis. — The  examination  by  the  test 
breakfast  should  follow  immediately  after  the  fasting  stomach  has 
been  emptied  by  aspiration.  No  attempt  should  be  made  to  wash  the 
stomach  nor  to  introduce  any  water  through  the  tube.  After  the 
fasting  stomach  contents  have  been  aspirated,  a  roll  and  a  glass  of 
water  should  be  given  and  the  products  of  digestion  removed  at  the 
expiration  of  an  hour. 

The  test  breakfast  may  or  may  not  be  indicative  of  pyloric  stenosis, 
and  compared  with  the  examination  of  the  fasting  stomach  is  of  inferior 
importance.     It  may  happen  that  aspiration  in  the  fasting  state  with- 


368  PYLORIC  SPASM  AND  PYLORIC  STENOSIS 

draws  a  quantity  of  acid  fluid  with  a  sediment  of  food  remains,  scanty, 
but  quite  sufficient  to  be  diagnostic,  while  the  test  breakfast  of  such  a 
case  examined  after  the  fasting  test  may  show  only  a  moderate  degree 
of  alimentary  hypersecretion;  the  total  quantity  aspirated  may  exceed 
the  normal,  and  the  supernatant  liquid  on  standing  may  be  far  greater 
in  depth  than  that  of  the  sedimentary  layer,  but  the  few  vestiges  of 
older  food  remains  that  would  establish  the  diagnosis  are  lost  amid 
the  greater  quantity  of  breadstuffs  of  which  the  test  breakfast  is  com- 
posed. Ancient  food  remains  are  easily  overlooked  in  test  breakfasts 
unless  present  in  fair  amounts  and  distinguishable  from  the  digested 
breadstuffs  by  color,  form,  or  outward  appearance.  Numberless  errors 
of  diagnosis  are  made  because  the  test  breakfast  is  alone  examined 
and  no  investigation  whatever  is  made  of  the  contents  in  the  fasting 
state.  Unless  the  fasting  examination  had  been  made  the  condition 
of  food-stasis  might  have  been  completely  overlooked. 

Benign  stenosis  is  regularly  accompanied  by  an  alimentary  hyper- 
secretion. The  test  breakfast  is  abundant  in  quantity  and  more  fluid 
in  consistency  than  normal,  ranging  from  200  c.c.  to  300  c.c,  but  occa- 
sionally being  even  more  copious.  Quantities  of  test  breakfast  exceeding 
one-half  liters  are  not  uncommon. 

In  mild  forms  two  layers  form  on  standing,  the  layer  of  supernatant 
fluid  being  more  than  equal  in  depth  than  that  of  the  lower  sedimentary 
deposit  of  well-digested  breadstuff's  with  a  probable  addition  of  older 
food  remains.  In  the  majority  of  cases  the  proportion  between  the 
two  layers  is  2  to  1  or  3  to  1,  but  exceptional  proportions  of  even 
10  to  1  are  encountered.  In  severe  types  three  layers  are  defined 
as  in  the  fasting  contents,  a  lower  sediment  of  new  and  old  food 
residue,  a  middle  or  liquid  zone,  and  a  floating  layer  of  food,  saliva, 
mucus,  occasionally  frothy. 

In  certain  cases  of  benign  stenosis  total  acidity  may  not  be  abnormally 
high,  attaining  only  the  normal,  or  in  exceptional  instances  being  far 
under  the  normal.  In  other  instances  the  total  acidity  may  be  normal 
or  over  the  normal,  while  the  acidity  that  is  due  to  free  hydrochloric 
acid  may  be  decidedly  subnormal.  It  may  be  demonstrated  that  in 
these  cases  the  greater  part  of  the  total  acidity  is  composed  of  loosely 
combined  hydrochloric  acid. 

Hyperacidity  is  not- a  necessary  accompaniment  of  benign  stenosis. 
Hypersecretion  is,  on  the  other  hand,  of  great  diagnostic  importance. 

■Gastric  Analysis  in  Malignant  Stenosis. — This  is  that  observed  with 
cancer  of  the  stomach  associated  with  food-stasis. 

Fasting  Stomach  in  Malignant  Stenosis. — The  fasting  stomach  regu- 
larly reveals  evidences  of  food-stasis  with  more  or  less  hypersecretion  of 
a  fluid  that  ma\'  consist  of  Indrofhloric  acid  alone,  of  Inrlrochloric  acid 


PYLORIC  STENOSIS 


369 


with  lactic  acid  or  of  lactic  acid  alone.  The  contents  are  often  exceed- 
ingly offensive,  foul,  or  even  fetid  or  putrid.  The  ordinary  tests  for 
occult  blood  are  usually  quite  well-marked.  Sarcinffi  are  rarely  present, 
except  in  the  transition  form  of  cancer  engrafted  upon  ulcer,  but  Oppler- 
Boas  bacilli  are  almost  regularly  present  in  stagnant  achlorhydric 
gastric  contents  containing  lactic  acid.  The  diagnostic  importance  of 
the  Oppler-Boas  bacilli  coincides  essentially  with  the  presence  of  lactic 
acid  itself,  and  their  detection  is  only  of  real  value  if  they  are  found  in 
a  specimen  which  gives  a  doubtful  lactic  acid  reaction. 


Fig.  70 


Fasting  contents  of  pyloric  stenosis  due  to  cancer.     Total  acidity,  2-1;  free  hydrochloric  acid,  0; 
lactic  acid  marked;  Oppler-Boas  bacilli  present;  blood  positive. 


Test  Breakfast  in  Malignant  Stenosis. — The  test  breakfast  shows 
the  characteristic  chemical  and  microscopical  examination  of  cancer  of 
the  stomach  generally,  -plus  food-stasis  and  a  tendency  toward  hyper- 
secretion. The  filtered  fluid  may  contain  free  hydrochloric  acid  alone 
or  lactic  acid  alone,  or  neither  form  of  acid  may  be  present.  Positive 
reactions  for  both  hydrochloric  and  lactic  acids  are  more  constantly 
present  than  in  the  benign  forms,  and  the  odor  is  more  offensix'e.  Blood 
is  almost  invariably  present  in  either  occult  or  visible  form,  though 
delicate  tests  may  be  required  before  positive  reactions  are  obtained. 

There  is  hardly  any  doubt  possible  as  to  the  nature  of  the  stenosis 
24 


370 


PYLORIC  SPASM  AND  PYLORIC  STENOSIS 


when  lactic  acid  is  present  in  stagnant  gastric  contents,  but  there  are 
a  large  number  of  cases  in  which  lactic  acid  and  other  suggestive  signs 
of  cancer  are  absent,  in  which  the  analysis  is  identical  with  that  of  nicer, 
so  that  a  differential  diagnosis  by  gastric  analysis  is  totally  impossible. 
Gastric  Analysis  of  Cases  of  Transition  of  Ulcer  of  the  Pylorus  into 
Cancer. — Beginning  in  the  early  stages  with  the  gastric  analysis  indica- 
tive of  ulcer- — food-stasis,  hypersecretion,  and  hyperacidity — there  is 
a  gradual  tendency  toward  a  reduction  in  hydrochloric  acid,  and  a 
formation  of  lactic  acid.  Sarcinse  hitherto  present  disappear  and  are 
replaced  by  the  lactic  acid  bacilli.  The  analyses  now  become  char- 
acteristic of  the  malignant  form.  The  early  cases  cannot  be  told  by 
gastric  analysis  alone  from  ulcer — the  ultimate  analyses  merge  into 
those  of  cancer.  It  is  only  the  intermediate  cases,  in  which  both  hydro- 
chloric acid  and  lactic  acid  are  present,  that  are  clearly  indicative  of 
malignant  degeneration  of  chronic  gastric  ulcer. 

Fig.  71 


Pyloric  stenosis:  honign  bowl-shapetl  residue  after  six  hours.     (Radiologist,  Dr.  Learning.) 


Radiographic  Diagnosis. — The  J{()ntgen  picture  of  ])yl()ric  stenosis  is 
c|uitc  c'liaracteristic.  On  the  plate  taken  six  hours  after  the  first  bis- 
nnith  meal  there  is  a  large  bowl-shaped  residue  of  bismuth,  which  ex- 
tends far  to  the  right  of  the  navel.  The  amount  of  bismuth  residue 
is  far  greater  than  in  simi)le  atony.  Uadi()gra])hs  of  the  stomach  taken 
immediately  after  the  second  bisnuith  suspension  meal  usually  show 
a  large  well-filled  stomach,  the  greater  curvature  of  which  sags  down- 
ward and  to  the  right,  passing  thence  upward  and  to  the  left  to  the 


PYLORIC  STENOSIS  371 

pylorus,  giving  to  this  portion  of  the  stomach  the  "undershot"  appear- 
ance of  a  bull-dog's  jaw.    Peristalsis  may  be  more  than  ordinarily'  active. 

For  the  differences  in  the  radiographic  findings  of  ulcer  with  or  with- 
out adhesions,  and  of  cancer,  the  reader  is  referred  to  these  respective 
headings.  The  radiographic  diagnosis  of  stenosis  is  much  inferior 
to  the  simpler  and  more  positive  evidence  of  finding  food  remains 
in  the  fasting  stomach  with  the  tube. 

Diagnosis  in  General.- — The  diagnosis  of  pyloric  stenosis  can  easily 
be  made  by  repeated  examinations  of  the  fasting  stomach,  but  the 
diagnosis  should  not  rest  with  that  of  the  pyloric  stenosis  alone,  without 
an  attempt  to  ascertain  whether  the  obstruction  be  organic  or  partially 
or  wholly  due  to  spasm  or  tumefaction,  and  furthermore,  to  decide,  if 
possible,  whether  we  are  dealing  with  the  benign  or  with  the  malignant 
form.  Gastric  analyses  should  be  made  at  intervals  throughout  the 
entire  course  of  benign  stenosis,  so  as  to  detect  as  early  as  possible 
any  deviations  that  might  indicate  beginning  malignancy. 

1.  The  extent  of  the  constriction  that  is  caused  by  spasm  or  conges- 
tive swelling  is  to  be  determined  by  the  intermitting  or  remitting  se\'- 
erity  of  the  symptoms,  by  repeated  examinations  of  the  fasting  stomach 
and  to  a  limited  extent  by  the  results  of  treatment.  The  diet  and  mode 
of  life  remaining  the  same  and  the  conditions  of  the  test  being  uniform, 
variations  in  the  amount  of  the  residual  contents  indicate  that  one 
or  both  of  these  remediable  factors  are  at  work,  although  the  conclu- 
sions may  not  be  accurate  in  all  cases.  It  is  conceivable  that  with  a 
fixed  degree  of  obstruction  in  front,  varying  degrees  of  muscular  effi- 
ciency behind  will  allow  of  great  variations  in  the  amount  of  propulsive 
work  actually  performed,  owing  perhaps  to  daily  variations  in  the 
nervous  strength  of  the  motor  impulses  conveyed  to  the  stomach  walls. 
It  is  always  advisable  unless  the  condition  call  for  immediate  surgical 
relief  to  estimate  the  variations  in  the  amount  of  the  residual  contents 
by  repeated  tests  and  to  attribute  the  minimum  quantity  of  residue 
to  organic  contracture,  and  the  difference  between  the  minimum  and 
the  maximum  quantity  of  retained  contents  to  the  effect  of  temporary 
factors.  To  remove  these  latter  causes  for  an  increase  in  the  mechanical 
obstruction,  is  the  one  object  of  our  medical  treatment.  Time  should 
not,  however,  be  spent  in  pottering  with  tests  when  malignancy  is 
suspected. 

2.  To  distinguish  clinically  between  benign  stenosis  of  the  pylorus 
and  that  produced  by  malignant  neoplasm  is  not  as  simple  a  matter  as 
it  may  appear.  Classical  examples  are  encountered  in  which  the  differ- 
ential diagnosis  is  obvious  and  could  be  made  by  those  even  of  limited 
experience  and  powers  of  observation,  while,  on  the  other  hand,  the 
symptoms,  physical  signs,  and  gastric  analyses  in  both  forms  may  be 


'.M2  PYLORIC  SPASM  AND  PYLORIC  STENOSLS 

identical.  Moreover,  the  symptoms  of  stenosis  of  undonbted  benign 
origin  may  gradnally  and  almost  imperceptibly  merge  into  those  of 
malignancy  from  the  slow  development  of  cancer  on  this  previous 
ulcer  base. 

It  is  impossible  therefore  to  contrast  the  points  of  dift'erential 
diagnosis  in  any  table  of  parallel  columns,  for  a  table  so  constructed 
cannot  endure  the  test  of  experience. 

It  is  said  that  a  past  history  of  ulcer  is  indicative  of  benign  stenosis; 
but  malignant  changes  may  develop  on  the  ulcer  base,  and  a  case  man- 
ifestly malignant  may  give  a  long  antecedent  history  of  chronic  ulcer, 
so  that  the  evidence  afi'orfled  by  the  history  is  faulty  and  misleading. 
A  sudden  onset  and  a  progressive  course  may  be  attributed  to  cancer, 
and  yet  chronic  obstruction  by  cicatricial  contraction  may  remain 
latent  until  the  sudden  appearance  of  stenotic  symptoms  which  run  a 
progressive  course,  while  on  the  other  hand  early  carcinoma,  especially 
if  engrafted  on  an  ulcer  base,  may  give  a  slow  insidious  onset  and  the 
symptoms  may  remain  practically  stationary  for  months. 

Gastric  analysis  often  proves  misleading,  except  that  lactic  acid, 
Oppler-Boas  bacilli,  and  evidences  of  ulceration  in  the  gastric  contents 
j)oint  to  malignancy.  The  combination  of  hydrochloric  and  lactic 
acids  with  either  sarcinse  or  lactic  acid  bacilli  in  a  patient  with  an 
ulcer  history  indicates  carcinomatous  degeneration  of  the  ulcer  with 
sufficient  distinctness  to  warrant  an  exploration. 

Each  case  has  therfore  to  be  decided  on  its  own  merits,  and  every 
point  in  relation  to  the  case  carefully  considered.  The  age  of  the  patient, 
his  previous  history,  the  subjective  symptoms  and  physical  signs,  the 
presence  or  absence  of  metastases,  the  results  of  repeated  gastric 
analysis,  the  question  of  an  advancing  chloranemia  or  cachexia  should 
all  be  weighed  in  the  balance  and  a  verdict  given  only  when  all 
evidence  is  carefully  and  judicially  sifted. 

From  a  practical  standpoint  the  advice  and  moral  sui:)p()rt  of  a  com- 
petent conservative  surgeon  should  be  requested,  and  in  cases  of  doubt 
an  exploration  is  generally  advisable. 

Prognosis. — Tlie  })rogn()sis  is  that  of  the  disease  of  which  pyloric 
stenosis  is  a  resulting  complication.  In  benign  stenosis  the  prognosis 
should  be  that  of  the  operation  done  for  its  relief,  and  should  not  exceed 
a  mortality  of  over  2  or  3  per  cent,  for  simple  gastrojejunostomy  ])ro- 
vided  that  the  operation  is  performed  by  a  competent  surgeon  with 
some  experience  in  abdominal  surgery.  A  higher  risk  attends  the  more 
radical  ojxTation  of  exsection.  Naturally  the  operative  risk  is  less 
when  tiie  ojKTation  is  performed  at  a  time  when  the  patient  is  in  com- 
paratively good  health  than  when  o])erati()n  is  resorted  to  as  affording 
the  only  ciiance  for  hfc  at  a  time  when  the  patient  is  practically  dying 
of  starvation. 


rVLOHJC  STEA'OSIS  373 

Many  untreated  cases  may  give  a  history  extending  over  years, 
either  steady  or  remittent.  If  the  lesion  l)e  extreme  the  course  is 
steadily  downward  and  is  attended  by  progressive  weakness,  emaciation, 
and  slow  starvation.  In  these  advanced  cases  vomiting  may  become 
quite  infrequent,  and  may  occur  only  after  intervals  of  several  days 
or  even  a  week;  but  when  it  does  there  are  vomited  such  large  quan- 
tities of  stagnating  fermenting  material,  "pailsful,"  as  the  patient 
may  express  it,  that  it  is  quite  evident  that  there  is  represented  the 
accumulation  of  days. 

If  during  the  course  of  chronic  pyloric  stenosis  acute  exacerbations 
occur  with  copious  watery  vomiting,  even  in  spite  of  total  abstinence 
from  all  food  and  drink,  the  symptoms  may  become  urgent  in  the  ex- 
treme, and  if  unrelieved  by  treatment  or  by  timel\'  surgical  intervention 
may  result  fatally  within  a  few  days. 

Tetany  was  formerly  regarded  as  a  complication  practically  hopeless, 
the  mortality  of  the  earlier  cases  amounting  to  90  per  cent.  Improve- 
ment in  medical  treatment  reduced  this  frightful  fatalit}'  to  70  per 
cent.  Recently,  however,  the  reports  of  cases  treated  surgically  have 
been  coming  in,  and  show  conclusively  that  the  hope  of  recovery  lies 
in  the  surgical  treatment  of  the  disease. 

The  latest  figures  available  are  those  of  McKendrik,^  who  has 
collected  24  operative  cases  of  gastric  tetany  with  but  3  deaths,  a 
mortality  of  12.5  per  cent.  Of  the  3  fatal  cases  death  was  due  to 
visceral  disease,  to  pneumonia,  and  to  peritonitis. 

In  cancer  the  prognosis  depends  upon  the  possibility  of  radical 
removal  of  the  neoplasm.  The  operative  risk  of  all  operations  for  cancer 
of  the  stomach,  whether  radical  or  palliative,  is  considerably  higher 
than  in  similar  operations  done  for  the  relief  of  benign  obstruction. 

Treatment. — Although  theoretically  the  treatment  of  pyloric  stenosis 
should  be  surgical,  nevertheless  there  are  mild  cases  which  get  along 
very  well  by  medical  means  alone,  and  which  improve  to  such  an 
extent  that  operative  interference  is  quite  unnecessary. 

For  those  who  are  about  to  undergo  an  operation  for  relief,  a  medical 
covirse  of  treatment  is  almost  invariably  indicated,  by  which  the 
stomach  may  be  emptied  of  its  stagnating  contents  and  cleansed,  and 
the  general  strength  and  nutrition  so  improved  that  the  patient  may 
be  better  able  to  withstand  the  surgical  ordeal  that  confronts  him. 

The  object  of  the  medical  treatment  is  to  reduce  if  possible  the 
degree  of  the  stenosis  by  relieving  concomitant  pyloric  spasm  and 
tumefaction,  as  well  as  to  feed  the  patient  and  improve  his  nutrition. 
]\Ieans  of  medical  relief  are  afforded  by  diet,  by  lavage,  and  by  drugs. 

1  Scottish  Medical  ami  Surgical  Journal,  1907,  xxi,  253. 


374  PYLORIC  SPASM  AND  PYLORIC  STENOSIS 

The  results  of  medical  care  are  better  shown  by  a  diminishing 
amount  of  residual  food  remains,  and  by  a  gain  in  weight,  than  by  any 
apparent  improvement  in  the  patient's  comfort  or  sense  of  well-being. 
Beneficial  effects  of  treatment  are  demonstrated  by  the  clear  fluid  of 
hypersecretion  being  found  in  the  fasting  stomach  instead  of  macro- 
scopical  food  remains. 

Dietetic  Treatment. — The  most  important  consideration  is  the  avoid- 
ance of  any  food  that  may  resist  digestion  and  persist  as  gross  food 
particles  too  large  to  readily  pass  the  constricted  pylorus.  The  food 
should  be  finely  comminuted,  thoroughly  masticated,  and  should  not 
contain  large  indigestible  particles,  such  as  grape-skins,  prunes,  or 
tough  and  gristly  portions  of  meat.  Food  that  is  mechanically  irri- 
tating, such  as  coarse  vegetables,  may  increase  the  liability  to  pyloric 
spasm. 

The  quality  of  the  food  depends  largely  on  the  digestive  power  of 
the  stomach.  In  benign  stenosis,  when  the  secretions  are  rich  in 
hydrochloric  acid  and  of  good  peptic  power,  the  quality  of  the  food  is 
quite  unimportant.  Should,  however,  hydrochloric  acid  be  absent,  as 
frequently  occurs,  with  malignant  stenosis,  the  proportion  of  nitrogen- 
ous food  should  be  reduced  and  food  rich  in  carbohydrates  should  be 
correspondingly  increased.  Although  we  may  attempt  theoretically 
to  regulate  the  diet  according  to  the  secretion  of  the  stomach,  prac- 
tically we  are  often  forced  to  disregard  these  theoretical  considerations 
and  to  arrange  the  diet  the  best  w^e  can  according  to  the  desires  of  the 
patient  and  his  ability  to  carry  out  the  dietetic  treatment  proposed. 

jNIore  important  than  the  quality  of  the  food  is  the  quantity  which 
may  be  taken  at  any  one  meal.  Pyloric  stenosis  is  an  indigestion  of 
quantities,  and  the  invariable  rule  should  be  to  insist  on  frequent  small 
meals,  so  that  the  burden  of  the  food  is  divided  throughout  the  day. 
At  least  five  or  six  meals  should  be  taken  daily.  A  great  deal  of  nourish- 
ment can  be  given  in  the  twenty-four  hours  without  overloading  the 
stomach  at  any  one  time  and  without  causing  distress  to  the  patient, 
whereas  a  single  large  meal  will  be  followed  by  pain  and  distress, 
often  so  severe  that  the  patient  bitterly  regrets  his  indiscretion. 

Liquids  should  be  restricted  at  the  time  of  the  meals,  but  may  be 
given  between  meals,  although  in  small  quantities  at  a  time.  Unless 
it  is  evident  that  the  pylorus  is  impervious  to  fluids  and  the  stomach 
is  distended  by  liquid  contents,  fluids  may  be  sipped  throughout  the 
day  so  that  a  total  sufficient  quantity  is  absorbed. 

It  has  been  recommended  that  the  diet  should  be  concentrated 
so  that  mechanical  distention  of  the  stomach  does  not  result  from 
mere  bulk.  Scraped  meats,  eggs,  concentrated  solutions  of  peptone, 
and  the  like  are  examples  of  the  food  advocated  according   to  this 


PYLORIC  STENOSIS  375 

principle.  An  opposed  view  is  that  the  diet  should  be  entirely  liquid 
so  that  the  nourishment  may  more  readily  pass  through  the  narrow 
outlet.  The  basis  of  such  a  treatment  is  milk.  The  writer  has  found 
it  impractical  to  adhere  to  either  of  these  extreme  forms  of  diet;  his 
preference  is  decidedly  for  solid  or  semisolid  foods,  finely  comminuted 
or  in  puree  form,  so  that  there  are  no  gross  food  particles  sufficient  in 
size  to  occlude  the  pylorus.  Milk  should  never  be  used  unless  thoroughly 
peptonized,  as  coagula  are  difficult  of  digestion  and  often  too  large  to 
escape  through  the  pylorus.  Milk  as  ordinarily  given  is  one  of  the 
worst  forms  of  food  that  can  possibly  be  devised  for  these  patients. 
If  milk  be  peptonized  the  warm  process  is  better  than  the  cool.  To 
peptonize  the  milk  completely,  the  author's  method  is  as  follows: 

To  a  pint  of  milk  add  J  pint  of  water.  Divide  the  milk  into  2  equal 
parts,  boil  one  and  to  it  add  the  other.  The  contents  of  one  Fairchild's 
peptonizing  tube  is  then  to  be  added  and  the  whole  of  amount  of  milk 
is  to  be  placed  in  stoppered  bottles  well  immersed  in  water  that  is 
distinctly  warm  to  the  hand  for  one  and  one-fourth  hours.  The  milk 
is  then  rapidly  boiled  and  placed  on  ice. 

A  simple  diet  for  advanced  pyloric  stenosis  may  be  arranged  as 
follows : 

8  A,M,  One-half  cup  of  cocoa,  soft-boiled  egg  with  fine  cracker  crumbs. 

10.30  A.M.  Scraped  beef  sandwich  with  bouillon. 

I  A.M.  Rather  thick  puree  of  vegetable,  such  as  pea  or  bean  soup,  a 
fine  cereal,  as  hominy  or  cream  of  wheat,  with  cream  and  sugar. 

3.30  P.M.  Malted  milk. 

7  P.M.  Creamed  toast,  baked  custard. 

In  less  severe  cases  the  diet  may  be  somewhat  more  varied,  although 
it  should  follow  the  general  principles  previously  indicated.  The 
heaviest  meal  should  preferably  be  at  mid-day,  and  the  evening  supper 
should  be  light  so  as  to  avoid  nocturnal  distress.  Such  a  diet  may  be 
outlined  as  follow^s: 

8  A.M.  Cup  of  cocoa,  two  soft-boiled  eggs,  fine  cereal. 

II  A.M.  Malted  milk. 

1  P.M.  Puree  of  vegetable  soup,  creamed  fresh  fish,  or  finely  chopped 
creamed  chicken,  mashed  potato,  or  any  vegetable  that  has  been 
passed  through  a  puree  sieve,  such  as  turnips,  carrots,  etc.  Corn-starch 
pudding. 

4.  P.M.  Cup  custard. 

7  P.M.  Fine  cereal,  scraped  beef  sandwich  or  poached  eggs  on  soft 
toast,  junket,  tapioca  or  rice  pudding. 

If  it  can  be  demonstrated  that  not  enough  fluid  is  being  absorbed 
by  the  system,  that  the  urine  and  blood  are  concentrated,  and  the 
tissues  are  in  an  abnormally  desiccated  condition,  fluids  should  be 


37()  PYLORIC  SPASM  AND  PYLORIC  STENOSIS 

introduced  into  the  system  in  every  possible  way.  In  these  cases 
there  is  very  httle  use  in  forcing  fluids  by  mouth.  The  jVIurphy  drip 
should  be  used  and  as  much  water  as  possible  induced  by  the  rectum. 
The  writer  prefers  normal  solutions  of  sodium  citrate  or  of  sodium 
bicarbonate  to  the  salt  solution  ordinarily  employed.  Glucose  up  to 
3  per  cent,  solution  may  be  used  in  combination  with  the  citrate,  and 
has  the  advantage  of  adding  nourishment  of  high  caloric  value  to  the 
fluid.  In  desiccated  subjects  on  whom  an  operation  is  advisable, 
fluids  should  be  introduced  into  the  system  in  large  amounts  prior 
to  the  operation.  If  haste  is  indicated,  hypodermoclysis  may  be 
employed. 

Treatment  by  Lavage. — The  stomach  should  be  usually  washed  every 
day  before  breakfast,  so  that  the  patient  starts  the  day  with  a  clean 
stomach.  The  morning  lavage  has  this  advantage  that  we  are  not  so 
likely  to  be  washing  out  from  the  stomach  nourishment  that  might  pass 
the  pA'lorus  and  become  absorbed,  and  moreo\'er,  the  stagnant  contents 
found  in  the  stomach  in  the  morning  are  really  quite  unfit  for  pro- 
pulsion into  the  intestine  for  absorption.  For  those  whose  stomachs 
fill  up  during  the  day  and  cause  nocturnal  distress  and  vomiting, 
lavage  may  be  recommended  either  before  dinner  or  at  bedtime. 
Washing  the  stomach  before  the  evening  meal  empties  it  of  its  previous 
accumulation  so  that  the  last  meal  of  the  day  finds  conditions  most 
favorable  for  its  easy  passage  and  absorption.  Lavage  the  last  thing 
at  night  will  naturally  benefit  distress  and  vomiting,  but  has  the  dis- 
advantage of  washing  out  nourishment  that  might  be  later  utilized. 
It  is,  therefore,  not  recommended  as  a  routine  procedure  to  be  used 
over  any  considerable  length  of  time,  but  may  be  resumed  from  time 
to  time,  especially  during  acute  exacerbations  of  the  ailment,  to  insure 
for  the  patient  a  good  night's  rest. 

In  very  advanced  cases  in  which  the  stagnant  stomach  contents  are 
abundant  and  fermenting,  it  is  better  to  empty  the  stomach  every 
morning,  and  if  necessary  before  the  evening  meal  as  well,  by  aspira- 
tion before  introducing  any  liquid  into  the  stomach  through  the  tube, 
as  it  may  happen  that  the  sudden  washing  of  the  stomach  may  be 
followed  by  gastric  tetany,  the  reason  for  the  occurrence  being  that 
the  toxins  are  dissolved  in  the  lavage  water  so  quickly  that  they 
pass  more  readily  through  the  pylorus  and  are  cjuickly  absorbed. 

Lavage  in  stenosis  is  usually  simple.  The  inflow  of  water  is  slow, 
but  the  return  is  usually  rapid  and  forcible,  so  that  the  residual  fluid 
after  the  lavage  is  generally  small  in  amount  compared  with  normal 
cases.  The  simple  tu})e  and  funnel  are  therefore  usually  sufficient 
provided  that  the  tube  be  of  sufficient  caliber  and  the  eyes  are 
large    enough  to  readily  admit  large  food  products.     The  ordinary 


PYLORIC  STENOSIS  377 

small  caliber  of  tubes  in  the  market  is  totally  inadequate  for  the 
purpose,  as  it  becomes  so  easily  blocked.  One  might  as  well  wash 
the  stomach  through  a  catheter  as  through  many  of  the  tubes 
commonly  employed. 

For  office  lavage  the  writer's  apparatus,  described  on  p.  (j8,  is  to 
be  recommended.  Lavage  should  })e  continued  at  each  sitting  until 
the  stomach  washes  clean,  even  though  this  may  take  considerable 
time  at  first.  After  the  stomach  has  once  been  thoroughly  cleaned 
and  kept  clean  for  a  time  lavage  becomes  easier  and  easier.  At  first 
the  washing  of  the  stomach  should  be  under  the  personal  supervision 
of  the  physician;  it  is  only  when  the  patient  becomes  an  adept  that 
he  may  be  intrusted  to  carry  out  his  own  treatment. 

The  writer's  preference  is  to  wash  with  plain  water.  The  object 
of  the  lavage  is  to  empty  the  stomach  of  its  contents  and  this  can 
be  done  with  plain  water  as  well  as  medicated  solutions,  with  the 
great  advantage  that  we  obviate  the  danger  of  poisoning  should 
large  quantities  of  residual  water  be  retained.  If  the  contents  of  the 
stomach  are  foul  or  fermenting,  the  writer  recommends  adding  suffi- 
cient essence  of  peppermint  to  the  lavage  water  to  give  it  an  agreeable 
odor  and  taste.  After  such  lavage  patients  feel  cleaner  and  more 
comfortable  than  they  do  after  plain  water  has  been  used.  Bicar- 
bonate of  soda  may  be  added,  a  dram  to  a  pint,  in  cases  with  high 
hydrochloric  acidity.  Among  the  various  forms  of  medication  that  have 
been  recommended  are  resorcin  in  1  per  cent,  solution;  salicylic  acid 
in  ^  per  cent,  solution;  thymol  in  \  per  cent,  solution;  ichthyol,  20  to 
30  drops  to  a  quart;  creolin  or  lysol,  10  drops  to  a  quart,  or  sodium 
benzoate  in  a  1  to  2  per  cent,  solution. 

If  any  of  these  forms  of  medication  are  used  the  return  flow  from 
the  stomach  must  be  measured  and  compared  with  the  amount  of 
medicated  water  introduced,  so  as  to  obviate  the  possibility  of  retention 
and  absorption  of  these  drugs. 

Drug  Treatment. — Oil  before  meals  is  often  of  service  in  reducing 
pyloric  spasm.  Plain  olive  oil  may  be  given  in  \  to  2-ounce  doses 
before  meals  or  a  single  large  dose  of  2  or  3  ounces  may  be  taken  on 
retiring.  A  3  per  cent,  solution  of  anesthesin  in  oil  may  be  given  in 
\  to  1-ounce  doses  before  meals,  and  often  proves  highly  beneficial 
in  reducing  a  possible  spasmodic  element  of  the  stenosis.  Oil  may 
also  be  given  through  the  tube  at  the  completion  of  lavage,  2  to  4 
ounces  of  the  warmed  oil  being  introduced  in  this  manner. 

Cohnheim  is  an  enthusiastic  advocate  of  the  oil  treatment,  and 
states  that  in  spastic  stenosis  that  an  absolute  cure  will  follow,  while 
in  cicatricial  stenosis  more  relief  is  obtained  than  after  any  other 
method  of  treatment.     He  recommends  the  washing  of  the  stomach 


378  PYLORIC  SPASM  AND  PYLORIC  STENOSIS 

in  the  morning  and  the  indnction  throngh  the  tube  of  100  to  150  c.c. 
of  warmed  oil.  After  this  the  patient  Hes  on  the  right  side  and  fasts 
for  one  hour.  If  the  pains  do  not  disappear  during  the  day  50  c.c. 
are  taken  before  retiring.  Later  in  the  treatment  a  wineglassful  an 
hour  before  breakfast  and  1  or  2  tablespoonfuls  one  or  two  hours  before 
dinner  and  supper  will  suffice  in  mild  cases.  Emulsion  of  almonds 
may  be  substituted  for  the  last  two  doses. 

Belladonna  or  atropine  are  often  of  service  in  reducing  pyloric 
spasm  and  may  be  given  a  trial.  The  writer's  results,  however,  have 
not  been  satisfactory  with  this  drug,  except  in  a  few  cases  of  sudden 
complicating  pylorospasm,  Math  the  constant  vomiting  of  acid  fluid. 
In  the  slow,  ordinary-  cases  of  pyloric  stenosis  no  good  has  apparently 
followed  this  medication,  while,  on  the  other  hand,  the  thirst  and 
dryness  of  the  mouth  have  been  intensified.  The  following  is  the  form 
in  which  the  drug  has  usually  been  given  and  may  be  recommended 
for  trial : 

I^ — Tinct.  belladonna 3ij 

Chloral  hydrate 3j 

Resorcin  resubl.  (Merck) 5j 

Strontii  bromid Siiss 

Aq.  chloroform 5iv 

Spirits  anisi gtt.  viij 

M.     Sig. — Teaspooiit'ul  in  a  wineglass  of  water  every  three  hours. 

When  hypersecretion  exists  with  a  high  degree  of  acidity,  alkalies 
are  of  use  in  reducing  the  acidity  and  making  the  patient  much  more 
comfortable.  According  to  the  observations  of  Hertz  and  others  the 
higher  the  acidity  the  greater  are  the  peristaltic  contractions  of  the 
stomach  wall.  A  reduction  of  the  acidity  will  therefore  reduce  the 
pain  and  discomfort  and  ma}'  minimize  pylorospasm.  When  alkalies 
are  given  they  should  be  given  in  sufficient  quantities  to  do  the  work. 
One  or  two  teaspoonfuls  of  bicarbonate  of  soda  may  be  required  at  a 
single  dose,  if  the  gastric  contents  be  copious  and  very  highly  acid. 

In  pyloric  stenosis  treatment  by  mineral  water  is  distinctly  contra- 
indicated.  The  stomach  has  enough  to  do  without  adding  to  its  burden 
large  amounts  of  water  that  are  recommended  at  the  medicinal 
springs.  Thiosinamine  has  been  superseded  by  an  analogous  prepara- 
tion, fi})rolysin,  as  a  possible  softener  for  cicatricial  tissue.  Fibro- 
lysin  may  be  obtained  in  sterile  form  ready  for  use  in  glass  bulbs, 
each  bulb  containing  2.3  c.c.  of  a  solution  of  1^  parts  fibrolysin  to  8| 
parts  distilled  water  (Merck).  Each  bulb  contains  a  single  dose  for 
hypodermic  injection,  and  should  be  given  into  the  gluteal  muscle  as 
injections  into  the  skin  may  be  followed  by  necrosis.  Any  untoward 
efl'ect  of  fibrolysin  may  be  obviated  In-  stopping  the  treatment  as  soon 


PYLORIC  STENOSIS  379 

as  the  odor  of  onions  appears  upon  the  l)reath.  The  author  has  had 
no  experience  with  the  preparation,  as  the  reports  of  cases  in  which 
it  has  been  used  have  been  exceedingly  disappointing. 

vStrychnine  has  been  recommended  to  increase  the  peristaltic  power 
of  the  stomach  so  as  to  force  its  contents  through  the  constructed 
outlet.  Heavy  massage  of  the  stomach  from  left  to  right  has  been 
recommended  for  the  same  purpose.  For  the  stimulation  of  peristalsis, 
hydrotherapy  has  also  been  recommended  in  the  form  of  cold  needle 
douches,  cold  showers,  and  alternating  hot  and  cold  needle  sprays. 
In  cases  of  pyloric  obstruction  in  which  peristalsis  is  visible  and  evident, 
there  seems  to  be  but  little  use  for  measures  whose  object  it  is  further 
to  increase  peristalsis.  The  muscular  power  of  the  stomach  is  good 
enough;  the  trouble  lies  in  the  resistance  in  front,  and  the  writer  does 
not  believe  in  increasing  peristalsis  artificially,  as  it  is  unwdse  to  over- 
work the  muscular  power  of  an  organ  that  is  doing  its  best.  For  this 
reason  the  writer  believes  that  strychnine,  hydrotherapy,  and  forcible 
massage  are  positively  contraindicated  in  this  disease. 

Hot  compresses  are,  however,  serviceable  as  a  means  of  reducing 
pyloric  spasm.  The  electric  pad  may  be  applied,  or  the  warm,  moist 
compresses  commonly  in  use.  These  have  been  described  under  the 
treatment  of  ulcer,  p.  173.  Relief  from  symptoms  often  follow  recum- 
bency, and  the  patients  learn  for  themselves  that  they  feel  better  when 
they  lie  down  after  meals.  Complete  rest  in  bed  for  several  days  or  a 
week  at  a  time  is  often  of  service,  and  should  be  recommended  in  severe 
cases.    In  many  instances  rest  in  bed  is  essential  to  improvement. 

Operative  Treatment. — In  benign  cases  of  stenosis  that  are  slight  and 
stationary,  the  patient  may  go  on  for  years  quite  comfortable  and 
content,  provided  he  follow  out  the  proper  diet  and  wash  his  stomach 
from  time  to  time.  Although  the  curative  treatment  of  these  patients 
is  surgical,  nevertheless  as  long  as  they  do  as  well  as  they  seem  to  be 
doing  it  is  not  common-sense  to  operate  on  them.  Operation  is  indicated 
by  any  of  the  following  conditions: 

1.  Operation  is  indicated  if  macroscopical  food  remains  be  con- 
stantly present  in  the  fasting  stomach  after  medical  treatment  has 
been  carried  out  faithfully  for  a  reasonable  period,  especially  if  the 
quantity  of  the  fasting  stomach  contents  show  a  tendency  to  increase, 
indicating  that  the  lesion  is  a  progressive  one.  Operation  is  naturally 
more  frequently  advised  in  young  individuals  who  otherwise  would 
have  to  spend  their  life  under  medical  treatment,  than  in  those  of 
advanced  years  who  are  content  to  get  along  as  they  are,  under  medical 
care.    The  operative  risk  is  naturally  much  greater  in  aged  patients. 

2.  Operation  is  indicated  if  the  lesion  be  so  extreme  that  not  enough 
food  can  pass  into   the  bowel   to  keep  the   patient  well   nourished. 


380  PYLORIC  SPASM  AND  PYLORIC  STENOSIS 

Surgery  is  indicated  whenever  there  is  a  progressive  loss  of  weight 
under  medical  treatment. 

3.  Operation  is  indicated  if  the  symptoms  of  pain  and  vomiting 
continue  in  spite  of  treatment. 

4.  Operation  is  indicated  should  acute  exacerbations  of  the  ailment 
occur,  characterized  by  profuse  vomiting  of  acid  fluid.  In  these  cases 
it  is  a  matter  of  nice  judgment  when  to  operate.  If  we  wait  too  long 
the  patients  are  exhausted  from  vomiting  and  by  their  loss  of  fluid. 
It  is  better  to  operate  too  early  than  too  late  upon  these  cases.  If, 
after  interdiction  of  all  food  and  fluids  by  mouth  the  vomiting  continue 
more  than  forty-eight  hours,  the  patient  should  receive  fluid  by  skin 
and  rectum  as  quickly  as  possible,  and  an  operation  done  at  the  first 
advisable  moment. 

5.  Gastric  tetany  is  a  cause  for  immediate  operation,  and  the  opera- 
tion should  invariably  be  preceded  by  or  accompanied  with  hypo- 
dermoclysis  and  the  induction  of  water  into  the  rectum  by  the  ]\Iurphy 
drip.  Calcium  lactate  should  be  given  in  gr.  xv  dose  every  three  hours 
by  mouth,  or  gr.  xx  every  three  hours  by  rectum. 

Surgery  is  indicated  whenever  there  is  the  least  suspicion  of  malig- 
nancy, and  exploration  should  be  performed  without  loss  of  time  so 
that  a  radical  operation  may,  if  possible,  be  done. 

Painstaking  examination  should  be  made  in  these  cases  for  any 
indications  of  inoperability,  such  as  enlarged  cervical  glands  or  implan- 
tation in  the  vesicorectal  pouch.  If  a  radical  operation  be  deemed 
impossible,  the  palliative  operation  of  gastrojejunostomy  may  be 
postponed  until  the  pyloric  stenosis  reaches  a  point  when  the  patient's 
nutrition  begins  to  fail,  or  when  the  symptoms  become  distressing.  In 
these  cases  it  is  not  wise  to  w^ait  too  long,  for  then  we  submit  a  patient 
who  is  debilitated  by  disease  to  a  severe  operation.  Gastrojejunostomy 
in  malignant  stenosis  may  be  followed  by  most  brilliant  results,  a 
cessation  of  pain  and  vomiting,  and  by  a  gain  in  nutrition  that  is  often 
most  striking. 

The  patient  may  feel  comparatively  well,  and  eat  almost  anything 
with  impunity,  and  such  a  period  of  im])rovement  may  continue  for 
some  months  after  the  operation  before  the  symptoms  reap])ear.  The 
downward  course  of  the  disease  is  then  usually  rapid. 


CHAPTER  XIII 

CONGENITAL  PYLORIC  STENOSIS 

INFANTILE   PYLORIC    STENOSIS 

Pyloric  stenosis  occurring  during  infancy  has  been  recognized  as  a 
clinical  entity  for  many  years,  but  it  is  only  since  the  attention  of  the 
profession  was  called  to  this  ailment  by  Hirschsprung  of  Copenhagen, 
in  1888,  that  the  disease  has  been  universally  recognized.  The  number 
of  recorded  cases  after  Hirschsprung's  paper  was  at  first  not  at  all 
numerous,  but  guided  by  the  accurate  description  of  the  symptoms  of 
the  condition  by  later  authorities,  more  and  more  cases  have  been 
correctly  diagnosticated,  and  the  additions  to  the  literature  of  the 
subject  have  become  more  numerous. 

Pathology. — The  essential  lesion  is  the  thickening  of  the  pyloric 
ring  from  hyperplasia  of  the  circular  muscular  fibers.  The  pyloric 
canal  assumes  a  funnel-shaped  or  a  cylindrical  form,  hard  and  incom- 
pressible. On  section  its  walls  are  thick  and  dense.  The  pyloric  orifice 
may  be  so  contracted  that  only  the  passage  of  a  fine  probe  is  possible. 
The  duodenal  end  of  the  pylorus  projects  into  the  duodenum,  and 
suggests  the  appearance  of  the  cervix  uteri  projecting  into  the  vagina. 
The  mucous  membrane  of  the  pyloric  canal  shows  usually  one  large, 
single,  longitudinal  reduplication  with  many  smaller  parallel  folds. 
This  longitudinal  reduplication  or  projection  of  the  mucous  membrane 
still  further  increases  the  stenosis.  The  muscular  hyperplasia  fades 
gradually  away  on  the  stomach  side  of  the  pylorus,  but  terminates 
rather  sharply  at  the  pyloric  ring,  although  it  is  possible  for  muscular 
hypertrophy  to  extend  outward  a  short  distance  into  the  duodenum. 
The  longitudinal  fibers  are  but  little  affected,  although  in  a  few  instances 
this  muscular  layer  shares  to  a  small  degree  in  the  hyperplastic  process. 
The  stomach  itself  is  usually  dilated.  Its  wall  in  the  pyloric  half  shows 
evident  muscular  hypertrophy,  which  fades  awa}'  toward  the  fundus 
so  that  the  wall  of  this  latter  portion  of  the  stomach  is  of  normal 
thickness,  or  may  even  be  thin. 

Etiology. — There  are  two  distinct  theories,  each  supported  by  com- 
petent and  experienced  clinicians  and  pathologists  to  account  for  this 
interesting  condition.  Each  theory  is  supported  by  facts  which  seem 
reasonable  and  plausible,  but  any  argument  for  one  or  the  other  theory 


382 


CONGENITAL  PYLORIC  STENOSIS 


may  be  opposed  by  an  equally  good  argument  against  it,  so  that  at  the 
present  time  judgment  as  to  the  true  nature  of  infantile  stenosis  must 


Fig.   72 

A 

t 

« 

\ 

■^j^H 

\ 

^ 

)) 

Transverse  section  of  normal  pylorus  of  an  infant.     Compare  with  photomicrograph    of    congenital 
stenosis.     (Shaw  and  Ordway,  American  Journal  of  Diseases  of  Children,  September,  1911  vol.  ii  ) 


Fig.   73 

S-..^_^^^^| 

V 

^^^■\^---- 

\ 

^Y 

Si                  V 

W&    iUm       a9v    ^"^^^^k^   ■~•'^- 

f"" 

L 

-J 

^^^v  ^^PV^^^B^^^v.             **( 

^ 

W 

- 

Congenital  hypertrophic  stenosis  of  pylorus.  L,  lumen  of  pylorus  much  contracted;  M,  mucosa; 
M,  M,  mu.scularis  mucosae;  5,  submucosa;  X,  very  much  hypertrophied  circular  muscular  coat.  At 
the  outer  edge  of  this  coat  one  can  see,  as  at  Y.  narrow  strips  of  the  longitiulinal  co.-it.  (From  the 
Pathological  I-aboratory  of  the  Babies  Hospital.) 


be  withheld.  A  study  of  the  cases  in  literature,  howe\er,  lead  us  to 
infer  that  there  are  two  distinct  pathological  conditions  which  give 
identical  ])hysical  signs  and  sym])toms,  one  of  which  is  amenable  to 


INFANTILE  PYLORIC  STENOSIS 


383 


medical  treatment  and  the  other  progresses  toward  a  fatal  termination 
unless  relieved  by  surgical  operation. 

The  first  theory  is  that  the  muscular  hyper])lasia  of  the  circular 
fibers  surrounding  the  pyloric  canal  is  an  error  in  development.  The 
pyloric  sphincter  is  essential  for  the  proper  mechanism  of  digestion,  and 


Fig.   74 

D-ii 

^^^^^^^^^ 

1 

A    •if'-'l 

VH^^                f^^M^  ^k^^"^ 

/ 

'       ii(i|inmii!|iMtjmi|iiimiii|illl  jlM|lil|  |||| 

!    0  M-M       1              2               3'             •''               5 
;    0       INCHES                          ,                                            2 

^   -hliljlililiJjijJ.lujJilihiiliLi 

/ 

f 

Congenital  hypertrophic  stenosis  of  the  pylorus  on  which  gastro-enterostomy  was  performed.  Gastro- 
enterostomy opening  through  which  a  glass  rod  is  inserted  is  seen  at  .Y.  The  p>-loric  canal  (P)  is  very 
markedly  narrowed,  the  walls  being  in  close  apposition.  The  very  marked  hypertrophy  of  the  circular 
coat  of  the  muscularis  with  its  fibrous  tissue  septa  is  seen  at  M.  Just  outside  of  this  the  longi- 
tudinal muscular  coat  may  be  seen.  The  submucosa  (S)  also  shows  hypertrophy.  A,  pyloric  valve; 
Z),  duodenum.     (From  the  Laboratory  of  the  Babies  Hospital.) 

nature  in  these  cases  has  simply  overdone  the  matter  and  has  supplied 
muscular  tissue  far  in  excess  of  the  quantity  required. 

Those  who  believe  in  this  theory  find  an  apparent  corroboration  in 
the  fact  that  infants  dying  early  in  the  course  of  the  disease  show  too 
much  muscular  tissue  for  it  to  have  been  formed  after  birth  by  a  process 


384  CONGENITAL  PYLORIC  STENOSIS 

of  compensatory  hypertrophy.  Those  who  oppose  this  theory  do  so 
oil  the  ground  that  were  the  process  truly  congenital  evidence  of  this 
error  in  development  would  occasionally  be  found  in  the  fetus,  whereas 
the  fetal  hyperplasia  of  the  pyloric  musculature  is  almost  unknown, 
only  one  case  having  been  recorded. 

The  second  theory  is  that  there  occurs  a  primary  spasm  at  the 
pylorus  to  overcome  the  resistance  of  which  a  muscular  hypertrophy 
takes  place.  This  spasm  may  be  of  intra-uterine  origin  and  probably 
results  from  disturbances  of  coordination  in  the  motility  of  the  fetal 
stomach,  or  the  spasm  may  occur  after  birth  from  fissure  or  erosion 
of  the  pylorus  or  duodenum.  Still  has  advanced  an  ingenious  theory 
that  the  spasm  is  the  result  of  "stomach  stuttering" — a  disturbance  of 
muscular  coordination  akin  to  the  stuttering  so  common  in  children 
who  are  learning  to  talk. 

Kiittner^  reports  2  cases  of  duodenal  ulcer  in  infants,  one  babe  being 
but  four  days  old,  probably  embolic  in  origin  from  thrombosis  of  the 
umbilical  vein,  and  speaks  of  the  possibility  of  many  cases  of  infantile 
pyloric  stenosis  being  due  to  the  spasm  thus  induced.  He  quotes  a 
case  of  von  Torda's,  in  which  an  infant,  aged  eight  months,  died  with 
a  clinical  picture  of  congenital  pyloric  stenosis,  and  in  which  the  cause 
for  the  condition  was  found  to  be  an  ulcer  of  the  duodenum  5  mm. 
below  the  pyloric  ring. 

Those  who  believe  that  the  lesion  is  a  muscular  hypertrophy  result- 
ing from  spasm  meet  the  argument  that  such  hypertrophy  requires 
more  time  for  its  development  than  seems  possible  in  the  cases  that 
die  early  in  the  disease,  by  saying  that  one  cannot  reason  from  the 
development  of  the  adult  to  that  of  the  infant  and  about  the  rate  of 
development  of   hypertrophy  in  infants  we  know  practically  nothing. 

Cautley-  regards  the  evidence  that  hypertrophy  results  from  pro- 
longed muscular  spasm  as  quite  unconvincing.  There  is  no  proof  of 
hypertrophy  following  spasm  in  other  ages,  and  there  is  no  reason 
M^hy  it  should  follow  in  infancy  and  not  at  other  times  in  life. 
Prolonged  anal  spasm  does  not  cause  hypertrophy  of  the  rectal 
sphincter.  Hypertrophy,  moreover,  does  not  disappear  after  gastro- 
jejunostomy as  it  should  do  were  it  caused  by  muscular  spasm. 
Cautley  draws  attention  to  the  fact  that  the  pylorus  is  normally  in 
a  state  of  contraction,  and  that  dilatation  occurs  only  in  response 
to  a  stimulus.  It  is  barely  credible  that  the  amount  of  spasm 
sufficient  to  oppose  the  stimulus  to  dilatation  can  be  great  enough 
to  produce  the  excessive  hypertrophy  of  the  circular  muscular  fibers 

>  Berlin,  nied.  Woch.,  1908,  No.  45. 

2  British  Jour.  Child.  Dis.,  190S,  p.  179. 


INFANTILE  PYLORIC  STENOSIS  386 

so  constantly  present.  If  the  longitudinal  fibers  possess  the  power 
of  dilating  the  sphincter,  it  cannot  be  explained  why  they  do  not 
hypertrophy  as  the  result  of  pyloric  spasm,  for  if  they  act  as  oppo- 
nents of  the  circular  muscular  fibers  one  would  expect  that  they  would 
undergo  hypertrophy  proportionate  to  that  of  the  circular  sphincter. 
In  accordance  with  this  reasoning  Cautley  regards  two  distinct  con- 
ditions as  proved — a  pure  pylorospasm  and  a  true  hypertrophy  of  the 
circular  muscular  fibers,  to  which  there  may  be  added  a  spasmodic 
contraction  from  time  to  time. 

Symptoms. — There  is  a  striking  similarity  in  the  clinical  course  of 
all  reported  cases.  Rarely  do  the  symptoms  begin  at  birth.  After  a 
period  of  time  varying  from  a  few  days  to  several  weeks,  during  which 
time  there  is  no  suspicion  of  impending  trouble,  the  infant  begins  to 
vomit  his  food,  at  first  at  somewhat  infrequent  intervals.  There  may 
be  no  apparent  reason  for  this,  as  the  child  may  be  breast-fed  or  nour- 
ished on  proper  scientific  principles.  The  vomiting,  however,  persists 
and  becomes  more  frequent,  so  that  nearly  all  nourishment  is  imme- 
diately rejected.  The  infant  begins  to  waste  and  looks  shrivelled  and 
marasmic.    The  symptoms  may  be  now  described  in  detail. 

Time  of  Onset. — It  is  rare  for  the  symptoms  to  appear  before  the 
third  or  fourth  day  of  life,  or  after  the  seventh  week,  although  the 
first  intimation  of  the  complaint  has  been  recorded  in  the  ninth  week 
after  birth.  The  average  date  of  the  onset  is  during  the  second  to  the 
fourth  week. 

Vomiting. — The  vomiting  begins  gradually,  occurring  at  first  but 
once  or  twice  a  day,  and  having  no  fixed  relationship  to  the  time  of 
feeding.  Within  a  short  time,  however,  the  vomiting  becomes  more 
frequent,  and  occurs  directly  after  the  feeding,  and  the  quantity  ejected 
increases  day  by  day.  It  may  be  noticed  that  nourishment  given  in 
small  quantities  may  be  retained,  but  that  larger  feedings  are  imme- 
diately ejected.  As  time  goes  on  the  amount  required  to  excite  vomiting 
grows  less,  so  that  even  minute  quantities  of  nourishment  are  at  once 
returned.  The  vomited  matters  may  be  slightly  altered  from  their 
condition  when  swallowed,  or  the  milk  may  be  curdled  and  admixed 
with  mucus.  Bile  is  almost  invariably  absent  from  the  vomitus, 
although  in  two  of  the  reported  cases  bile  was  present,  causing  con- 
siderable uncertainty  in  the  diagnosis. 

Characteristic  of  infantile  stenosis  is  the  remarkable  violence  of  the 
vomiting,  the  vomited  matter  being  ejected  with  great  force,  often 
projectile  in  character,  or  even  forced  through  the  nostrils.  Equally 
diagnostic  of  the  condition  is  the  vomiting  of  a  large  quantity  of  food 
when  only  a  small  quantity  has  been  previously  given,  showing  that 
the  vomit  represents  more  than  one  feeding,  perhaps  the  accumu- 
25 


386  CONGENITAL  PYLORIC  STENOSIS 

lation  of  several  that  have  been  retained  in  the  dilated  stomach.    The 
characteristics  of  the  vomiting  as  given  by  Still  are: 

1.  Its  forcible  character. 

2.  Its  occnrrence  in  a  child  that  has  been  carefully  fed. 

3.  Its   persistence  in  spite  of  changes  in  diet. 

4.  A  quantity  returned  more  than  that  recently  taken,  suggesting 
accumulation  in  the  stomach. 

5.  Its  association  with  constipation,  for  usually  vomiting  in  infants 
goes  with  loose,  slimy  stools. 

The  general  condition  generally  goes  from  bad  to  worse,  the  infant 
loses  steadily  in  weight,  proportionate  to  the  severity  of  the  vomiting, 
often  weighing  toward  the  close  of  the  disease  barely  three  or  four 
pounds.  The  face  becomes  pinched  and  shrunken  and  the  child 
has  an  old  and  wizened  look.  The  temperature  runs  a  subnormal 
course.  Constipation  is  well-nigh  invariable,  as  would  be  naturally 
inferred  from  the  impossibility  of  sufficient  nourishment  passing  into 
the  bowel  to  give  substance  to  the  stools.  Convulsions  may  appear 
from  time  to  time,  either  from  desiccation  of  the  tissues  or  from  toxic 
absorption  of  the  accumulation  of  food  in  the  stomach. 

Physical  Signs.^ — Physical  signs  in  the  early  days  of  the  disease  may 
not  be  apparent,  but  after  the  symptoms  have  existed  a  short  time 
examination  affords  conclusive  proof  of  the  presence  of  the  disease. 
Inspection  shows  that  from  time  to  time  the  outline  of  the  stomach  is 
distinctly  visible  and  that  faint  waves  of  contraction  pass  from  left  to 
right  over  the  surface  of  the  organ.  Reversed  peristalsis  may  also  be 
evident  just  preceding  the  act  of  vomiting.  As  time  goes  on  the  peri- 
staltic waves  become  more  and  more  evident,  so  there  may  be  visible 
lumps  varying  in  size  from  a  walnut  to  a  tangerine,  arising  at  the  left 
costal  margin  and  passing  slowly  across  to  the  right.  Such  a  stately 
peristaltic  wave  may  be  followed  by  2  or  3  similar  elevations  resembling 
a  chain  of  hills.  These  peristaltic  waves  are  distinctly  visible  two  or 
three  yards  away,  thus  distinguishing  them  from  the  feeble  peristalsis 
which  is  often  observed  passing  over  the  stomachs  of  infants  who  sufl'er 
from  vomiting  and  consti])ation,  which  can  be  seen  only  by  a  strong 
and  oblique  light.  These  ])eri.staltic  waves  are  easily  recognized  as 
quite  different  from  the  irregular  contractions  of  the  abdominal  wall 
occasionally  seen  in  squirming  infants.  It  should  be  remembered  that 
visible  peristalsis  occurs  only  at  certain  intervals,  and  therefore  the 
examiner  should  take  sufficient  time  in  his  search.  A  patient  examina- 
tion often  occupying  ten  or  fifteen  minutes  may  be  necessary  before 
the  signs  can  be  elicited,  and  occasionally  a  second  or  even  a  third 
examination  may  be  required.  Moreover,  the  abdomen  should  be 
examined  immediately  after  the  infant  has  been  fed,  for  the  peristalsis 


INFANTILE  PYLORIC  ^STENOSLS 


387 


may  not  be  evident  at  any  other  time  than  this.  The  stomaeh  is 
usually  quite  dilated  in  size  and  somewhat  inflated,  causing  a  prominence 
in  the  epigastrium  in  striking  contrast  to  the  collapsed  and  sunken 
appearance  of  the  lower  ])art  of  the  a})domen  overlying  the  empty 
intestines. 

A  tumor  is  often  palpable  in  the  jjyloric  region,  usually  in  the  right 
nipple  line,  one-third  of  the  way  between  the  umbilicus  and  the  right 
costal  arch,  and  seems  hard  to  the  touch,  cylindrical  in  form,  and  freely 
movable.  Such  a  mass  may  not  be  noticed  until  after  several  weeks 
of  vomiting,  and  even  then  may  be  demonstrable  at  certain  times 
and  not  at  others,  for  the  presence 

of  a  tumor  depends  upon  the  tem-  Fig.  75 

porary  condition  of  the  muscle  at 
the  pylorus.  If  the  muscle  be  in  a 
condition  of  tonic  contraction  a 
tumor  is  felt,  but  if  the  muscular 
tissue  be  relaxed;  the  pylorus  may 
become  so  soft  that  it  eludes  the 
most  experienced  touch.  For  this 
reason  the  tumor  is  usually  most 
easily  detected  during  the  period 
of  evident  peristalsis,  and  becomes 
less  evident  when  the  stomach  is 
in  a  relaxed  condition. 

It  has  been  recommended  that 
the  examination  for  the  growth 
should  be  made  under  an  anes- 
thetic in  doubtful  cases.  It  would 
seem,  however,  that  the  effect  of 
the  anesthetic  would  be  to  relax 
the  stomach,  abolish  the  tonic  con- 
traction at  the  pylorus,  and  render 

detection  most  difficult.  The  most  reasonable  time  for  examination 
would  be  directly  after  the  feeding,  when  peristalsis  and  tonic  con- 
traction of  the  pylorus  are  most  marked. 

Prognosis. — The  prognosis  is  extremely  serious,  the  mortality  being 
about  50  per  cent.  The  mortality  under  varied  conditions  of  treat- 
ment, medical  and  surgical,  is  well  illustrated  by  StilP  in  a  verbal 
report  at  the  Clinical  Society  of  London.  Of  23  cases  under  his  per- 
sonal observation,  14  recovered  (8  after  surgical  treatment,  6  after 
medical  treatment).  Of  the  9  that  died,  3  were  untreated,  3  died  after 
operation,  3  died  after  medical  treatment. 


Infantile  pyloric  stenosis.     (Case  of  Dr.  Charles 
L.  Gibson;  radiologist.  Dr.  Le  Wakl.) 


1  Lancet,  Marcli  10,  1907,  p.  734. 


388  CONGENITAL  PYLORIC  STENOSIS 

Treatment. — Recognizing  that  in  infantile  stenosis  there  exists  a 
definite  obstruction  to  the  onward  passage  of  food  into  the  intestine, 
the  natural  inference  would  be  that  surgical  intervention  would  con- 
stitute the  one  and  only  form  of  treatment.  The  danger  is  that  the 
brilliancy  of  surgical  operation  leads  us  into  the  error  of  resorting  to 
surgery  as  a  routine. 

If  the  stenosis  be  due  to  an  irremediable  hyperplasia  of  the  pylorus, 
surgery  would  afford  the  only  means  for  relief.  If,  on  the  other  hand, 
compensatory  hypertrophy  be  a  phenomenon  secondary  to  pyloro- 
spasm,  we  have  reason  for  attempting  to  relieve  the  condition  by 
medical  means  before  resorting  to  an  operation.  It  is,  therefore 
advisable  to  see  that  the  medical  treatment  is  carefully  and  judiciously 
carried  out  for  a  certain  period  of  time  at  least  before  advising  surgical 
interference  in  these  young  infants. 

The  medical  treatment  consists  chiefly  in  the  washing  of  the  stomach 
and  the  regulation  of  the  diet. 

The  stomach  should  be  washed  at  least  once  a  day  for  a  prolonged 
period,  and  in  bad  cases  lavage  twice  a  day  may  be  required.  Plain 
water  may  be  used,  or  a  weak  solution  of  bicarbonate  of  soda,  2  grains 
to  an  ounce.  It  is  a  simple  process  in  young  infants,  and  if  properly 
done  leads  to  no  discomfort  or  disturbance. 

It  should  be  done  before  the  feeding,  at  a  time  when  under  normal 
conditions  the  stomach  should  be  empty.  After  lavage  has  been  con- 
tinued for  a  certain  time  there  is  usually  a  marked  improvement  in 
the  infant.  The  vomiting  ceases,  the  bowels  begin  to  act  normally, 
the  visible  peristalsis  becomes  less  evident,  and  finally  disappears, 
and  the  child  improves  in  apparent  comfort  and  begins  to  gain  in 
weight.  Improvement  in  the  vomiting  by  lavage  is  often  misleading, 
as  the  vomiting  may  cease  within  a  few  days  after  beginning  the 
treatment  even  though  the  residual  food  may  be  as  great  as  before, 
showing  no  actual  improvement  in  the  stenotic  process.  The  obvious 
sign  of  improvement  is  a  diminution  in  the  quantity  of  residual  food 
that  is  washed  out,  showing  that  a  certain  part  of  the  food  at  least  is 
making  its  way  into  the  intestine.  This  improvement  both  in  objec- 
tive and  subjective  signs  may  ai)i)ear  quite  imexpectedly  in  the  very 
worst  cases  of  marasmic  infants  with  repeated  vomiting  and  well-marked 
gastric  peristalsis,  just  the  sort  of  case  which  would  seem  hopeless  at 
the  start. 

Dietetic  Treatment. — The  efi'ect  of  change  of  diet  is  most  evident 
when  previous  errors  have  existed.  In  infants  who  have  been  scien- 
tifically nourished  or  who  are  breast-fed  very  little  can  be  done  by 
changing  the  rharac-ter  of  their  food.  The  amoiuit  of  nourishment 
taken  at  each  feeding  is,  howexer,  quite  important,  as  small  quantities 


aONdENITAL  STENOSIS  IN  ADULTS  389 

at  short  intervals,  such  as  1  or  2  ounces  every  one  or  two  liours  may  l)e 
retained,  while  larger  amounts  of  the  same  nourishment  may  be  ejected. 

Much  information  can  be  obtained  by  inspection  of  the  residual  food 
removed  from  the  stomach  by  lavage.  To  pass  the  narrowed  pylorus, 
the  nourishment  should  be  flocculent  and  semiliquid.  If  the  milk  in 
a  given  case  returns  curdled,  a  change  in  nourishment  is  indicated, 
either  the  use  of  w^hey  or  of  peptonized  milk,  or  any  form  of  modified 
milk  that  is  not  capable  of  gross  coagulation. 

Diarrhea  may  come  on  during  the  treatment  as  a  complication.  The 
intestine  not  being  used  to  the  presence  of  chyme  seems  to  become 
irritated  and  to  give  rise  to  diarrhea,  always  serious,  and  occasionally 
fatal.  When  such  a  diarrhea  occurs  the  food  should  be  reduced  to 
half  quantities  at  least,  and  it  is  claimed  that  half-grain  doses  of  gray 
powder  twice  or  three  times  a  day  are  of  service. 

Drug  Treatment. — Drugs  of  antispasmodic  nature  are  of  very  little 
use.  Bromides,  ethereal  spirits,  valerian,  and  the  various  preparations 
of  opium  have  been  recommended,  but  the  benefits  are  not  comparable 
with  those  derived  from  lavage  and  regulation  of  the  diet,  and  the  use 
of  drugs  in  young  and  weak  infants  is  often  fraught  with  danger. 

Saline  solution  may  be  given  by  rectum  to  supply  fluid  to  the  desic- 
cated tissues. 

The  length  of  time  medical  treatment  should  be  continued  is  a 
matter  of  nice  judgment  on  the  part  of  the  physician.  If  the  patient 
seems  to  be  gaining,  then  there  is  no  necessity  for  a  hasty  resort  to 
surgery,  and  the  medical  treatment  may  then  be  continued  as  long  as 
the  infant  continues  to  improve.  A  certain  degree  of  improvement  at 
least  is  expected  in  nearly  all  cases.  When  this  improvement  comes 
to  a  standstill  with  symptoms  of  the  original  malady  still  persisting, 
though  of  a  diminished  severity,  the  time  has  come  to  decide  whether 
the  risk  of  operation  with  a  prospect  of  complete  restoration  is  not 
preferable  to  the  prolongation  of  a  medical  treatment  that  ceases  to 
be  beneficial.  Gastrojejunostomy  or  pyloroplasty  should  then  be 
recommended. 


CONGENITAL    STENOSIS    IN    ADULTS 

In  1879  Landerer  observed  the  case  of  a  man,  aged  forty-five  years, 
who  for  years  had  suffered  from  stomach  disorder.  After  death  there 
was  found  an  enormously  dilated  stomach  without  structural  change 
or  thickening  at  the  pylorus,  although  the  outlet  was  so  small  as  to 
measure  only  2  mm.  in  diameter.  Landerer  collected  9  other  instances 
of  narrowing  of  the  pylorus  in  those  between  forty-three  and  sixty-three 


390  CONGENITAL  PYLORIC  STENOSIS 

years  of  age  in  his  postmortem  experience,  although  in  these  instances 
a  previous  history  was  not  available. 

The  writer  has  seen  one  instance  of  this  congenital  smallness  of  the 
pyloric  orifice. 

A  man,  aged  fifty-two  years,  entered  the  hospital  with  arterio- 
sclerosis, dilatation  of  the  heart  with  decompensation  symptoms,  and 
died  on  the  fifth  day  after  admission  without  having  given  any  obvious 
gastric  symptoms. 

Autopsy  revealed  a  large,  thin-walled  stomach.  The  pylorus  was 
normal  in  every  respect  except  that  it  was  infantile  in  size,  barely 
admitting  a  slate-pencil.  There  was  no  overgrowth  of  muscular  tissue 
or  any  signs  of  active  or  healed  ulceration. 

Maier,^  in  1885,  contributed  31  cases  found  at  autopsy  in  which  the 
condition  seemed  to  be  congenital.  The  ages  varied  from  12  to  75,  and 
in  no  instance  was  the  narrowing  associated  with  any  gross  structural 
change  of  the  pylorus,  although  in  certain  of  his  cases  an  appreciable 
amount  of  thickening  of  the  pylorus  was  found,  apparently  of  con- 
genital origin.  This  was  before  Hirschsprung's  paper  describing  the 
hypertrophic  congenital  stenosis  in  infancy.  On  reading  Maier's 
reports  we  are  struck  with  the  resemblance  of  certain  of  his  cases  with 
those  of  pyloric  stenosis  of  infancy,  so  that  it  would  seem  that  mild 
degrees  of  the  infantile  form  not  incompatible  with  life  might  persist 
and  be  evident  even  in  extreme  age. 

Russell^  calls  attention  to  the  fact  that  cases  of  supposed  congenital 
narrowing  of  the  pylorus  as  described  by  Maier  are,  however,  not  seen 
in  infancy,  so  that  the  nature  of  the  condition  is  rendered  obscure. 

Maylard'^  reports  having  encountered  narrowing  of  the  pylorus  which 
was  difficult  to  explain  on  the  basis  of  any  organic  or  functional  derange- 
ment. It  was  either  found  difficult  to  insert  the  index  finger  into  the 
pylcjric  orifice  or  the  finger  was  felt  to  be  gripped  by  a  uniformly 
narrowed  ring  without  indication  of  cicatrization  from  ulcer  or  any 
evidence  of  spasmodic  closure.  The  only  construction  possible, 
according  to  this  writer,  is  that  the  condition  represents  a  congenital 
abnormality,  the  aperture  not  developing  sufficiently  to  meet  the 
normal  requirements.  Maylard  reports  in  his  article  12  cases  in  addi- 
tion to  7  previously  reported,  but  of  these  6  gave  a  history  of  the 
vomiting  of  blood,  so  that  doubt  is  thrown  upon  the  accuracy  of  his 
observations. 

ilussell^  reports  3  cases  of  supposed  congenital  origin,  which  seem 
to  the  writer  to  be  more  conclusive,  although  locahzcd  fibrosis  of  the 
pyloric  canal  cannot  be  ruled  out. 

>  Virch.  Arch.,  1885,  cii,  4i:}.  =  British  Med.  Jour.,  July  11,  1912. 

=>  Ibid.,  1908.  ^  Liincot,  June  20,  1908. 


CONGENITAL  STENOSIS  IN  ADULTS  391 

It  is  reasonable  to  suppose  that  eongenital  pyhjric  stenosis  may  be 
encountered  in  adult  life,  either  as  the  end  result  of  a  hypertrophic 
pyloric  stenosis  of  infancy  that  has  not  been  severe  enough  to  cause 
the  early  death  of  the  patient,  or  from  malformations  of  the  pyloric 
canal,  usually  of  the  funnel-shape  described  by  Maier,  which  has 
persisted  during  the  life  of  the  individual.  That  instances  of  either 
form  of  the  disorder  are  rare  cannot  be  doubted. 

Dr.  Wollstein,  of  the  Babies  Hospital,  in  New  York,  in  a  verbal 
communication  states  that  mild  forms  of  pyloric  stenosis  due  to  an 
increase  in  the  circular  muscular  fibers  of  the  pylorus,  of  the  congenital 
infantile  type,  have  not  been  encountered  at  post  mortems  done  on 
children  dying  of  intercurrent  disease.  In  a  letter  to  the  author  Dr, 
Codman,  of  Boston,  writes  that  at  the  Massachusetts  General  Hos- 
pital there  has  been  no  case  of  pyloric  stenosis  in  adults  comparable 
to  that  of  infants — that  is,  due  to  muscular  hypertrophy  without  lesion 
of  the  mucosa.  His  opinion  is  based  on  the  operation  records  of  the 
hospital  from  1877  until  the  present  time  (September,  1912).  Dr, 
Finney,  on  the  other  hand,  writes  from  Baltimore:  "In  half  a  dozen 
or  more  cases  there  was  a  distinct  thickening  and  hypertrophying  of 
the  circular  muscle  about  the  pylorus,  without  any  demonstrable 
lesion,  old  or  recent,  in  the  mucous  membrane.  I  thought  at  the  time, 
and  still  do  think,  that  it  was  probably  congenital." 

Dr.  W.  J.  Mayo  writes,  in  response  to  a  letter  of  inquiry:  "We 
have  seen  three  or  four  cases  of  the  type  you  mention,  in  which  there 
was  a  history  of  trouble  in  infancy  and  more  or  less  trouble  up  to  the 
time  of  operation,  in  which  the  condition  resembled  pyloric  stenosis 
of  infancy,  and  in  which  great  muscular  thickening  existed." 

Symptoms. — There  is  a  long  history  of  stomach  trouble  dating  back 
to  childhood,  characterized  by  acute  attacks  of  greater  severity.  The 
symptoms  in  the  main  are  those  of  chronic  pyloric  stenosis  of  the 
benign  acquired  form,  distress  after  meals,  evidences  of  increased 
peristalsis,  and  the  vomiting  of  food.  The  gastric  analyses  and  physical 
diagnosis  are  identical  with  those  of  the  ordinary  benign  form,  and 
the  diagnosis  can  only  be  made  if  these  signs  and  symptoms  date 
back  to  childhood  and  if  a  careful  history  elicited  no  data  that  would 
suggest  previous  ulceration  or  perigastric  adhesions. 

Treatment. — The  treatment  is  that  of  the  benign  form-  of  acquired 
stenosis. 


chaptp:r  XIV 

HOUR-GLASS  STOMACH 

Hour-glass  stomach  is  the  condition  in  which  the  stomach  is  divided 
into  two  portions  by  a  constriction  at  any  point  between  the  cardiac 
and  the  pyloric  orifice.  The  term  is  a  useful  one  in  many  ways, 
although  it  is  hardly  accurate  when  applied  to  cases  in  which  three  or 
more  pouches  exist,  and  to  which  the  term  segmented  stomach  seems 
to  be  more  applicable. 

Forms. — Hour-glass  contraction  may  occur  in  one  of  three  forms: 

1.  Congenital. 

2.  Acquired  organic. 

3.  Functional. 

Congenital  Form. — The  congenital  form  is  extremely  rare,  so  that  its 
occurrence  has  generally  been  doubted.  ]\lorgagni  believed  strongly 
in  heredity,  and  mentions  a  family  in  which  three  generations  presented 
this  defect.  Other  writers  regard  the  anomaly  as  defective  de^'elop- 
ment,  the  pyloris  part  remaining  of  the  intestinal  type,  while  the 
cardia  end  alone  expands  to  form  the  true  stomach. 

Sandifort  has  observed  an  hour-glass  stomach  in  a  fetus.  Whether 
this  case  was  one  of  defective  development,  or  the  result  of  intra- 
uterine gastric  ulcer  which  had  undergone  spontaneous  cure  leaving 
the  stomach  deformed,  cannot  be  proved. 

Acquired  Form. — Acquired  organic  hour-glass  stomach  is  the  ordinary 
form  seen  in  operative  cases.  Schomerus  in  1014  gastric  operations 
found  7  per  cent,  presented  this  deformity.  It  is  probable  that  with 
the  increasing  number  of  gastric  operations  during  the  past  few  years, 
later  statistics  will  show  the  condition  to  be  somewhat  less  frequent 
than  this. 

The  cause  for  the  acquired  form  is  either  ulcer,  cancer,  or  perigastric 
adhesions.  Of  these  ulcer  is  the  most  frequent  cause  for  the  deformity. 
Saddle-back  ulcers  of  the  lessor  curvature  are  more  frequently  followed 
by  the  condition  than  similar  lesions  in  other  parts  of  the  stomach. 
Postulcerous  hour-glass  stomach  can  be  produced  by  the  contraction 
and  induration  accom])anying  the  healing  of  the  ulcer,  so  that  the 
lower  curvature  is  pulled  up  toward  the  lesser  to  form  a  constriction 
ring,  the  upper  portion  of  which  is  composed  of  dense  scar  tissue,  the 
lower  portion  of  nornial   stomach  wall.     In  other  instances  the  nicer 


PLATE    IX 


Fig.   1 


Tight  Organic  Hour-glass  Stomach.  The  neck  does  not  emerge 
froiTi  the  niost  dependent  part  of  the  upper  segment.  (Radiologist, 
Dr.    Learning.) 


Fig.  2 


'rifid  or  Tripartite  Stov-nach.        (Case  of  Dr.    Charles   L.   Gibson; 
radiologist,   Dr.    Le  Wald.) 


PLATE    X 


Fig.    1 


Fig.    2 


Fig.  1. — Hour-glass  Stomach.  Plate  taken  shortly  after  the  bismuth  meal, 
showing  poueh-like  sagging  of  the  upper  segment  lying  in  front  of  the 
neck  and  obscuring  it.      (Radiologist,   Dr.   Learning.) 

Fig.  2. — Hour-glass  Stomach.  Same  ease  as  Fig.  1,  taken  two  hours 
later,  showing  bismuth  residue  still  remaining  in  the  upper  segment. 
(Radiologist,   Dr.    Learning.) 


Fig.  3 


Spasmodic  Hour-glass  Stomach.  Clinical  history  of  prolonged  vomiting 
and  emaciation.  Exploration  showed  normal  stomach  and  was  followed 
by  a  cessation  of  all  symptoms.  (Case  of  Dr.  H.  H.  M.  Lyle ;  radiologist, 
Dr.    Le  Wald.) 


FORMS  OF  HOUR-GLASS  STOMACH  393 

may  })e  more  circular,  so  that  the  constricting  ring  is  largely  comjjosed 
of  scar  tissue  alone. 

In  the  great  majority  of  instances,  subdivision  of  the  stomach  into 
two  pouches  occurs  3  or  4  inches  from  the  pyloric  orifice.  In  Schomerus' 
series  of  98  cases,  51  were  near  the  pylorus,  34  midway,  and  13  near 
the  cardia.  When  near  the  cardia,  the  pyloric  pouch  is  large,  so  that 
the  cardiac  portion  may  be  overlooked.  There  have  been  instances 
in  which  anastomosis  was  done  between  the  pyloric  pouch  and  the 
jejunum  without  benefit  to  the  patient,  from  lack  of  care  in  determining 
the  point  of  obstruction. 

In  cases  of  multiple  ulcerations  hour-glass  stomach  may  be  com- 
plicated by  pyloric  stenosis  or  by  similar  contractions  in  the  duodenum. 
Such  cases  have  been  reported  by  Moynihan  and  W.  J.  Mayo.  Similar 
contraction  deformities  may  follow  corrosive  poisoning  or  the  healing 
of  syphilitic  ulcers. 

Hour-glass  stomach  from  cancer  is  rare  except  in  malignancy' 
implanted  on  a  chronic  ulcer.  The  mode  of  origin  is  the  same  as 
in  the  postulcerous  form  except  that  the  lumen  of  the  isthmus  ma}' 
be  encroached  upon  by  the  malignant  growth. 

Hour-glass  contraction  may  be  due  to  adhesions.  Connective  tissue 
bands  may  pass  as  a  bridle  from  one  curvature  to  the  other,  drawing 
them  together  and  rendering  the  stomach  wall  undistensible  in  the 
constricting  line,  or  a  band  may  pass  from  the  stomach  to  the  anterior 
abdominal  wall  in  such  a  manner  that  the  stomach  hangs  over  it  on 
each  side  like  saddle-bags.  Langerhans  describes  a  case  in  which 
there  was  a  cicatrix  in  the  middle  of  the  lesser  curvature  and  the  cor- 
responding portion  of  the  posterior  wall,  from  which  a  peritoneal  band 
passed  to  its  insertion  in  the  anterior  abdominal  wall,  so  completely 
contracting  the  body  of  the  stomach  that  the  finger  could  barely  be 
passed  through  the  constricted  portion. 

An  interesting  type  of  hour-glass  stomach  may  occur  when  adhesions 
form  between  ulcers  of  the  lesser  curvature  and  the  under  surface  of 
the  liver.  When  the  patient  stands  a  line  of  tension  is  produced  diag- 
onally downward  across  the  stomach  holding  up  the  greater  curva- 
ture at  this  point,  while  on  either  side  of  this  line  the  lower  border 
of  the  stomach  sags  perceptibly  downward,  producing  the  semblance 
of  an  hour-glass  stomach  which  disappears  when  the  patient  lies 
down. 

Hour-glass  stomach  is  a  predisposing  cause  for  volvulus,  the  pyloric 
portion  usually  rotating  upward  and  to  the  left.  The  cardiac  pouch 
in  these  cases  is  not  involved  in  the  torsion  so  that  the  cardiac  orifice 
remains  patent  and  the  swallowing  of  food  and  vomiting  are 
possible. 


394 


HOUR-GLASS  STOMACH 


Symptoms. — The  symptoms  at  first  depend  largely  upon  the  cause, 
be  it  ulcer,  cancer,  or  perigastritis,  but  when  the  deformity  has  fully 
developed  the  symptoms  are  more  distinctive  and  resemble  those  of 
stenosis  either  in  the  pyloric  or  the  cardiac  orifice.  If  the  constriction 
ring  be  near  the  cardia  the  symptoms  are  those  of  difficulty  in  swallow- 
ing and  the  immediate  regurgitation  or  vomiting  of  recently  ingested 
food,  so  that  from  the  history  alone  it  may  be  difficult  to  decide  between 
an  esophageal  diverticulum  and  an  hour-glass  contraction  at  the  cardiac 
end  of  the  stomach.  If  the  contraction  be  in  the  middle  or  toward 
the  pyloric  end  the  symptoms  are  those  of  j^yloric  stenosis.     Until  the 


Fig.  70 


Spasmodic  hour-glass  stomach.    Imji.-.un.  ul  fireater  curvature  from  ulcer  of  lesser  curvature  adherent 
to  the  liver.    Sketch  made  at  the  time  of  operation.     (From  Dr.  J.  C.  Bloodgood.) 

adoption  of  tiie  .r-ray  in  diagnosis  the  condition  was  usually  found 
at  autopsy  or  quite  unexj)ectedly  at  oi)cration,  no  suspicion  of  its 
existence  having  been  entertained  but  by  the  adoption  of  this  modern 
means  of  examination,  the  diagnosis  is  being  made  in  an  increasing 
number  of  cases.  This  is  shown  by  the  fact  that  Moynihan  diagnos- 
ticated the  condition  correctly  in  one  out  of  six  of  his  first  series,  and 
in  seven  out  of  nine  of  the  cases  that  came  later  under  his  observation. 

Physical  Signs. — The  diagnosis  of  hour-glass  contraction  by  physical 
signs  is  made  cither  by  the  use  of  a  tube  or  by  the  .r-ray. 

Exdiiiindiioii  1)1/  Mcdn.s  of  the  Tiihc. — A  number  of  tests  have  been 
recorded   for  the  detection  of  the  deformitx',  wjiicli   are  more  or  less 


AM  DIoaiiA  /'///(■   1)1  A  (IN  OS  IS  395 

N'iiluahlc,  hut  are  at  tlie  present  time  so  inferior  in  accurac-y  to  a 
ra(lio<iraphic  examination  that  they  are  not  re^anU'd  as  hearing  more 
than  corroborative  testimony  to  the  existence  of  the  disorder.  Their 
greater  vahie  consists  in  arousing  suspicion  of  the  disorder  when  they 
occur  in  the  routine  examination  of  a  patient  with  serious  iiuHgestion, 
or  under  coiuhtions  in  which  facihties  for  an  .r-ray  examination  are 
not  at  hand. 

The  foUowing  tests  may  be  enumerated: 

1 .  By  the  induction  of  water  through  the  tube  there  may  be  a  visible 
prominence  in  the  left  hypochondrium,  subsiding  in  a  few  seconds  and 
then  appearing  further  over  to  the  right  side.  The  passage  of  the 
liquid  through  the  isthmus  is  usually  accompanied  by  audible  gurgling 
sounds. 

2.  When  water  is  so  introduced,  it  may  be  found  that  the  larger 
part  cannot  be  removed  from  the  stomach  by  aspiration,  suggesting 
that  it  has  passed  into  the  second  pouch.  This  is  known  as  "Wolfler's 
hrst  sign."  The  writer  regards  it  as  absolutely  inconclusive,  as  it  is 
often  difficult  to  recover  water  from  an  atonic  stomach  that  is  otherwise 
normal. 

3.  If  water  be  introduced  that  cannot  be  recovered,  even  though 
splashings  be  heard  indicating  the  pressure  of  liquid  in  the  stomach, 
it  may  be  that  the  fluid  has  flowed  into  the  pyloric  pouch,  where  it 
cannot  be  reached  by  the  tube.  This  is  known  as  the  "paradoxical 
dilatation"  of  Jaworski.     It  is  not  a  sign  of  much  value. 

4.  If  on  washing  the  stomach  the  water  returns  for  a  time  quite 
clear  and  then  suddenly  there  occurs  a  gush  of  cloudy  fluid,  it  would 
indicate  the  passage  of  gastric  contents  from  a  filled  pyloric  pouch  into 
the  cardiac  sacculation  that  has  been  cleansed  by  the  lavage.  This 
is  known  as  "Wolfler's  second  sign,"  and  is  regarded  by  ]\Iayo  Robson 
as  possessing  considerable  diagnostic  significance.  When  this  phe- 
nomenon occurs,  suspicion  of  hour-glass  stomach  should  always  be 
entertained,  but  the  writer  has  found  this  sign  present  when  no  hour- 
glass contraction  has  existed. 

5.  Inflation  of  the  stomach  by  artificial  dilatation  may  show  a 
distention  of  the  upper  pouch  which  subsides  as  the  gas  passes  through 
the  isthmus  to  dilate  the  stomach  more  generally.  The  outline  of  the 
l)iloculated  stomach  may  then  be  apparent. 

().  The  transillumination  of  the  cardiac  pouch  by  gastrodiaphany 
is  totally  inaccurate  and  unsatisfactory. 

Radiographic  Diagnosis. — Organic  Hour-glass. — The  organ  is  seen 
to  consist  of  two  sacs  connected  by  a  narrow  isthmus,  the  appearance 
being  the  same  in  all  the  plates.  ^  ery  characteristic  is  it  when  both 
sacs  contain  bismuth  surmounted  })y  an  air-bubble.    Eciualiy  character- 


39() 


HOUR-GLASS  STOMACH 


istic  is  the  fact  that  the  neck  does  not  enier<;e  from  the  most  dependent 
portion  of  the  upper  sac,  hut  from  a  point  higher  up,  the  lower  jjortion 
of  the  upper  segment  passing  downward  and  to  the  left  from  the  emer- 
gence of  the  communicating  channel.  The  upper  segment  is  usually 
more  dense  in  shadow  than  the  lower  one,  and  repeated  examinations, 
as  by  the  fluoroscopic  method,  show  that  the  upper  sac  empties  itself 
gradually  into  the  lower  cavity. 

The  isthmus  is  usually  smooth  in  ulcer,  shows  nodular  indentations 
if  cancerous  stricture  be  present.  Should  the  isthmus  pass  from  the 
posterior  surface  of  the  upper  sac,  the  channel  may  be  obscured  by  the 
most  dependent  portion  of  the  upper  cavity  hanging  like  a  curtain 
before  it.  The  six-hour  plate  may  show  a  bowl-shaped  food  residue 
in  the  upper  sac,  still  obscuring  the  outlines  of  the  isthmus.  These 
appearances  are  well  seen  in  the  accompanying  radiographs. 


Fig.   77 


Spasmodic  liour-glass  stomach  with  no  ulceration.     A,  spasm  present;  B,  spasm  disappeared  after 
vigorous  contraction  of  abdominal  muscles.     (Hertz.) 

Spastic  Hour-glass  (Hypertonic  Type). — 1.  In  organic  pyloric  stenosis 
witii  increased  peristalsis  u  contraction  wave  may  start  near  the  fundus 
and  completely  separate  the  contents  of  the  pylorus  from  the  rest  of 
the  stomach.  Radiographs  will  show  an  apparent  hour-glass,  differing 
from  the  organic  form  in  three  particulars:  (a)  The  neck  comes  from 
the  most  dependent  i)orti()n  of  the  upper  segment;  (b)  the  constriction 
ring  is  equally  shown  on  ui)per  and  lower  curvature;  and  most  impor- 
tant of  all  is  that  (c)  the  condition  a])i)ears  on  some  i)lates  and  not  on 
others,  showing  the  contraction  wave  to  be  but  a  transient  one. 

2.  With  ulcer  of  the  lesser  curvature,  a  deej)  contraction,  indenture, 
or  incisure  may  be  seen  on  the  lower  curvature.  This  api)earance 
usually  indicates  adhesions  to  the  liver,  and  is  then  apparent  only 
when  the  patient  stands,  the  line  of  traction  often  disai)pearing  if  the 
])lates  are  taken  in  the  recumbent  position.  In  other  cases  a  more 
permanent  incisure  is  seen  with  lesser  curvature  ulcers  even  in  the 
absence  of  adhesions,  and  remains  fixed  in  a  series  of  plates  regardless 


RADIOGRAPHIC  DIAGNOSIS  397 

of  the  position  of  the  patient.  The  same  appearance  ma.v  also  be 
due  to  carcinoma  of  the  lesser  curvature,  especially  if  engrafted  on  an 
old  ulcer  or  adherent  to  the  liver.  According  to  Hertz,  spasmodic 
hour-glass  contraction  may  often  be  made  to  disappear  by  abdominal 
massage,  contraction  of  the  abdominal  muscles,  and  by  injections  of 
atropine. 

Before  h^'pertonic  functional  hour-glass  contraction  can  be  diag- 
nosticated and  the  organic  form  excluded,  a  series  of  plates  should  be 
taken  on  different  days,  both  in  the  erect  and  recumbent  position. 
Suspicion  of  functional  hour-glass  should  always  be  entertained  when- 
ever one  deep  incisure  only  is  seen  on  the  greater  curvature,  and  the 
probability  considered  of  the  presence  of  an  ulcer  with  or  without 
adhesions  on  the  lesser  curvature.  In  hypertonic  contraction  the 
spasm  does  not  seem  to  prevent  the  rapid  filling  of  the  distal  pouch, 
nor  does  it  lead  to  increased  peristalsis  in  the  proximal  pouch  during 
the  continuance  of  the  spasm  (Hertz). 

In  spite  of  all  precautions  mistakes  are  made.  The  accompanying 
plate  (Plate  X,  Fig.  3)  was  taken  of  a  patient  who  for  years  had 
suffered  from  persistent  epigastric  pain  and  vomiting.  The  incisure 
was  present  in  a  fixed  spot  in  all  the  plates,  and  food-stasis  seemed  to 
exist  as  bismuth  was  present  in  the  stomach  thirty-five  hours  after  the 
bismuth  meal.  Exploration  showed  a  perfectly  normal  stomach,  free 
from  ulcer  or  adhesions.  A  radiographic  plate  taken  two  weeks  after 
the  operation  showed  no  evidence  of  the  former  indentation.  The 
gastric  symptoms  ceased  after  the  exploration  and  have  never  returned . 

3.  In  other  instances  a  portion  of  the  lower  curvature  may  be  caught 
up  by  adhesions  attacked  directly  to  the  affected  area.  Such  incisures 
are  apt  to  vary  materially  with  changes  in  the  position  of  the  patient, 
and  usually  disappear  entirely  in  the  Trendelenburg  position. 

Hypotonic  Hour-glass  Stomach, — Hypotonic  hour-glass  is  but  rarely 
observed,  although  it  is  described  by  Hertz  as  not  infrequent. 

In  combination  of  ptosis  with  extreme  degrees  of  atony,  the  most 
dependent  portions  of  the  stomach  sag  more  and  more  deeply  as  food 
is  taken,  and  the  tension  exerted  on  the  body  of  the  stomach  results 
in  the  narrowing  of  the  passage  between  the  fundus  and  the  portion 
of  the  stomach  that  is  sagged  down  by  the  weight  of  the  food,  until 
the  lumen  is  finally  obliterated  and  the  stomach  is  divided  into  two 
segments,  the  upper  containing  the  air-bubble  and  the  lower  sagged 
portion  containing  the  food.  As  more  food  is  taken,  part  of  it  may 
remain  in  the  upper  portion,  so  that  each  portion  may  contain  food 
and  an  air-bubble.  This  apparent  hour-glass  condition  disappears 
when  the  patient  lies  down. 

It  is  ini])()rtant  U)  remember  that  if  the  plate  be  taken  while  the 


398 


HOUR-GLASS  STOMACH 


patient  is  on  the  back,  the  stomach  may  He  across  the  vertebral  column 
so  that  the  pars  media  is  raised  while  both  extremities  of  the  organ 
sag  backward,  forming  bismuth  pools  on  either  side,  while  the  central 
portion,  overlying  the  vertebrae,  is  unfilled  and  drawn  into  a  somewhat 
narrow  isthmus.  The  ruga^  are,  however,  quite  distinct  and  the  apparent 
hour-glass  disappears  when  the  patient  stands.  The  appearance  may 
closely  resemble  tumor  of  the  i)ars  media. 


Fig.  78 


Orthostatic  or  hypotonic  hour-glass  stomach.    .4,  vertical  position,  first  stage;  B,  vertical  position, 
second  stage;  C,  horizontal  position.       (Hertz.) 


Treatment. — If  the  isthmus  between  the  two  sacculations  is  of  fair 
size,  the  patient  may  get  along  fairly  well  on  the  medical  treatment 
that  is  adopted  in  cases  of  pyloric  stenosis.  By  medical  means  alone 
the  nurition  may  be  improved  and  the  patient  rendered  more  comfort- 
able, but  no  permanent  results  are  to  be  expected. 

The  curative  treatment  is  entirely  surgical.  A  number  of  different 
operations  for  the  relief  of  this  condition  have  been  devised.  They 
consist  of  digital  divulsion ;  of  gastroplasty  analogous  to  the  pyloroplasty 
of  Finney;  of  gastrogastrostomy  or  the  lateral  anastomosis  of  the  two 
pouches.  Gastrojejunostomy  is  applicable  to  tiie  cases  in  which  the 
constriction  occurs  close  to  the  pyloris.  In  some  instances  gastrectomy 
may  l)e  deemed  advisable.  The  exact  surgical  technicjue  to  be  adopted 
cannot  be  decided  upon  uiilil  the  iibdonien  is  opened. 


CHAPTER   XV 
DIAPHRAGMATIC  HERNI A— p] VENTR ATION— ^'0L^■  IJLUS 
DIAPHRAGMATIC  HERNIA 

Diaphragmatic  hernia  consists  in  the  protrusion  of  one  or  more 
of  the  abdominal  viscera  into  the  pleural  cavity  through  a  congenital 
defect,  through  a  rent  or  tear  as  the  result  of  traumatism,  or  through 
one  of  the  natural  orifices. 

Forms. — According  to  the  variety  of  the  opening  in  the  diaphragm, 
is  based  the  division  of  diaphragmatic  hernia  into  congenital  or  trau- 
matic and  of  acquired  cases. 

Congenital  Hernia. — Congenital  hernia  is  the  most  frequent  form. 
Of  433  cases  collected  by  Grosser  in  1899  a  congenital  origin  could  be 
demonstrated  in  232.  In  Knaggs'  series  of  63  cases,  24  were  congenital, 
21  traumatic,  and  S  were  acquired,  the  herniated  parts  passing  through 
one  of  the  normal  existing  orifices  of  the  diaphragm. 

If  it  be  considered  that  a  peritoneal  sac  is  essential  to  hernia,  few  of 
the  reported  cases,  now  over  600  in  number,  can  be  considered  instances 
of  hernia,  as  a  hernial  sac  properly  speaking  does  not  occur  with  the 
traumatic  and  but  rarely  with  the  congenital  form.  The  term  is,  how- 
ever, used  in  a  broad  sense  to  include  all  the  cases  of  displacement  of 
the  abdominal  viscera  into  the  thoracic  cavity  irrespective  of  whether 
or  not  they  may  be  inclosed  within  a  peritoneal  sac.  In  Grosser's 
series  of  433  cases  a  true  sac  was  found  in  but  10  of  the  acquired  and 
in  30  of  the  congenital  cases.  In  266  cases  collected  by  Lacher  a  true 
sac  was  present  in  only  28  instances. 

A  distinction  must  be  made  between  diaphragmatic  hernia  and 
eventration.  In  the  latter  condition  there  exists  weakening  of  the  dome 
of  the  diaphragm,  so  that  under  normal  intra-abdominal  pressure  the 
diaphragm  bulges  upward  to  form  a  sacculation  into  which  enter  one 
or  more  of  the  abdominal  viscera.  The  diaphragm,  e\'en  though  thinned 
and  undeveloped,  still  remains  as  a  limiting  membrane  lying  between 
the  diaphragmatic  layers  of  the  peritoneum  and  of  the  pleura  so  as 
to  form  a  true  and  unbroken  sac. 

Diaphragmatic  hernia  is  almost  always  left-sided.  In  Arnheim's 
series  of  284  cases,  reported  by  Cliadbourne,^  the  right  side  was  afi'ected 

1  Amor.  Jour.  Med.  Sci.,  1903,  312,  cxx. 


Lacher  ( 

;276  cases, 

161 

times 

145 

times 

83 

times 

96 

times 

43 

times 

35  times 

20 

times 

27 

times 

2 

times 

400  DIAPHRAGMATIC  HERNIA 

in  but  8  per  cent.,  the  reason  for  this  relative  immunity  being  obviously 
due  to  the  presence  of  the  liver  which  acts  as  a  buffer,  protects  the 
diaphragm  on  that  side  from  the  effects  of  increased  abdominal  pressure, 
and  closes  very  efficiently  any  defect  that  may  occur.  Almost  every 
abdominal  organ  except  the  rectum  and  the  pelvic  viscera  have  been 
found  in  the  hernia,  as  may  be  shown  by  the  following  table  of  hernial 
contents  compiled  by  Rochard  and  Lacher: 

Rochard  (330  cases). 

Stomach 187  times 

Colon 177  times 

Small  intestine 133  times 

Omentum 107  times 

Spleen 78  times 

Liver 60  times 

Duodenum 48  times 

Cecum 35  times 

Pancreas 32  times 

Kidneys 3  times 

To  show  how  varied  the  contents  of  the  hernia  may  be,  Knaggs' 
complication  of  59  cases  will  be  interesting. 

Table  .showing  the  Various  Associated  Viscera  in  the  Herni.e 

Stomach  alone 9 

Stomach  and  part  of  duodenum 3 

Stomach  and  omentum 5 

Stomach  and  spleen 3 

Stomach,  spleen,  pancreas,  and  colon 6 

Stomach,  spleen,  and  transverse  colon 22 

Stomach,  liver,  spleen,  omentum,  and  small  intestine   ....  2 

Stomach,  liver,  and  small  intestine 3 

Stomach  and  almost  all  the  abdominal  viscera 1 

It  is  seen  that  in  Knaggs'  series  in  which  the  stomach  was  involved, 
the  colon  was  implicated  in  33,  the  spleen  in  16,  and  the  pancreas  in  5, 
in  each  instance  being  associated  with  hernia  of  the  spleen  and  colon. 
In  some  cases  the  colon  alone  was  involved. 

Right-sided  hernia  are  usually  small  and  often  contain  small  knob- 
like protrusions  of  the  liver. 

Mechanism.— The  mechanism  of  diaphragmatic  hernia  is  frequently 
quite  involved,  so  that  many  of  the  cases  are  difficult  to  understand 
even  at  autopsy.  Passage  of  the  stomach  through  the  hernial  ring  is 
seldom  a  simple  upward  movement,  but  is  complicated  in  the  great 
majority  of  instances  by  torsion  either  in  the  longitudinal  or  the  vertical 
axis,  causing  a  complicating  volvulus,  often  with  resulting  strangulation 


FORMS  OF  DIAPHRAGMATIC  HERNIA  401 

symptoms  or  even  perforation.  When  the  stomach  and  colon  are 
found  in  the  hernia  the  colon  often  lies  uppermost  and  the  stomach 
is  so  twisted  on  its  longitudinal  axis  that  the  lower  curvature  points 
upward  and  forward,  so  that  the  organ  is  upside  down,  seeming  to 
prove  that  the  colon  first  enters  the  hernial  orifice  and  then  drags  the 
stomach  after  it,  so  that  the  lower  curvature  is  the  next  to  engage. 
The  resulting  volvulus  is  of  the  "receding  car-wheel"  type.  This  is 
the  view  taken  by  Payer,  and  it  seems  to  be  corroborated  by  patho- 
logical findings,  although  Knaggs  claims  that  usually  the  stomach  enters 
first,  dragging  the  colon  after  it  by  means  of  the  gastrocolic  omentum. 
Whenever  the  pyloric  portion  of  the  stomach  enters  the  esophageal 
or  other  neighboring  openings  of  the  diaphragm,  as  in  the  acquired 
form,  a  rotation  on  a  vertical  axis  is  bound  to  occur.  If  the  opening 
be  to  the  left  of  the  cardia  the  rotation  naturally  is  of  180°  and  the 
lesser  omentum  is  sharply  twisted  on  itself,  so  that  the  cardiac  portion 
of  the  stomach  that  is  not  in  the  hernial  sac  is  poorly  supplied  with 
blood,  softens,  and  may  become  gangrenous.  The  pyloric  portion, 
provided  that  the  diaphragmatic  opening  be  not  too  narrow,  is  well 
supplied  by  blood  by  the  right  coronary  and  gastroduodenal  arteries. 
In  the  cases  of  Knaggs  and  Willetts,^  in  which  a  gastric  hernia  took 
place  through  the  normal  esophageal  opening  (Knaggs'  to  the  left  of 
the  cardia,  Willett's  to  the  right)  gangrene  of  the  cardia  occurred,  while 
the  herniated  portion  was  easily  reducible  and  of  good  nutrition. 

If  the  hernial  opening  be  of  small  size,  the  portions  engaging  in  the 
orifice  may  be  compressed  by  tumefaction  or  by  the  wedging  in  of  a 
portion  of  the  omentum,  so  that  strangulation  of  the  portions  of  the 
viscera  within  the  thoracic  cavity  may  occur,  rarely,  however,  at  the 
seat  of  actual  constriction.  Gangrene  may  also  result  or  splits  through 
the  peritoneal,  or  muscular  coats  produced  by  extreme  distention  may 
determine  the  site  of  perforation  whenever  the  softening  mucous  mem- 
brane gives  way.  The  pleura  may  participate  in  the  inflammation 
and  a  considerable  pleuritic  exudate  may  result.  When  the  aperture 
is  small,  either  the  esophagus  may  be  compressed  or  twisted,  so  that 
deglutition  is  impossible,  or  should  similar  obstruction  occur  at  the 
duodenal  end  nothing  can  pass  downward.  The  herniated  portions 
may  for  considerable  periods  of  time  be  free  to  enter  the  hernial  orifice, 
and  after  a  time  undergo  spontaneous  reduction.  This  is  the  history 
of  many  patients  whose  hernial  orifice  is  large  and  free  from  adhesions. 
When  adhesions  occur  in  the  vicinity  of  the  aperture,  spontaneous 
reduction  may  be  rendered  impossible,  and  the  condition  becomes 
more  or  less  permanent.     Distention  of  the  portion  of  the  stomach 

1  Lancet,  August  6,  1904 
26 


402  DIAPHRAGMATIC  HERNIA 

included  in  the  hernia  almost  invariably  occurs,  either  as  a  transient 
condition  capable  of  natural  relief,  or  permanent  and  progressive, 
especially  if  strangulation  or  torsion  should  occur. 

Congenital  Diaphragmaiic  Hernia. — Congenital  diaphragmatic  hernia 
takes  place  either  through  some  developmental  defect  of  the  diaphragm 
or  through  unclosed  pleuroperitoneal  passages,  the  latter  being  the 
route  taken  in  21  of  26  cases  reported  by  Keith. ^ 

Hernia  through  the  left  pleuroperitoneal  passage  is  the  usual  route 
in  the  congenital  cases,  although  defects  may  be  at  any  portion  of  the 
diaphragm  or  may  even  take  place  through  the  normal  esophageal 
opening.  Defects  in  the  right  leaflet  are  apt  to  be  blocked  by  protrusions 
of  the  liver.  The  aperture  may  vary  in  size  from  2  cm.  in  diameter  to 
the  entire  absence  of  half  the  diaphragm.  Extensive  congenital  defects 
of  the  diaphragm  are  frequently  accompanied  by  anomalous  lack  of 
development  of  the  lung.  In  a  case  reported  by  Beckman-  exploratory 
operation  revealed  congenital  absence  of  the  diaphragm  and  lung  on 
the  left  side. 

Traumatic  Hernia. — Rents  and  tears  from  trauma  may  occur  in  a 
greater  \'ariety  of  situations  than  in  the  congenital  form,  although  the 
closure  of  the  aperture  by  the  liver  in  case  of  right-sided  lacerations 
usually  prevents  visceral  intrusion.  Laceration  of  the  diaphragm  may 
be  due  to  stab  wounds  or  to  bullet  injuries,  to  crushing  of  the  body,  as 
in  buffer  or  coupling  accidents,  or  being  run  over,  to  severe  blows  upon 
the  abdomen  or  lower  thorax,  or  to  falls  from  a  height.  A  sudden 
doubling  up  of  the  body  with  the  chest  between  the  knees,  as  in  sand 
or  gravel  slides,  may  be  the  cause  for  the  tearing  of  the  diaphragm 
tissue.  In  21  traumatic  cases  collected  by  Knaggs,  7  were  due  to 
l)ullet  or  stab  wounds,  8  to  crushes,  6  to  falls  from  a  height. 

The  orifice  at  first  is  of  the  nature  of  a  rent  or  tear,  but  if  the  patient 
survives  it  becomes  more  or  less  circular  with  callous  well-defined  edges 
which  may  be  adherent  to  neighboring  parts  or  to  such  viscera  as 
may  be  found  passing  through  it.  The  injury  may  be  a  serious  one,  as 
in  stab  wounds  or  body  crushing,  or  the  traumatism  may  be  ajiparently 
insignificant  and  not  attended  by  any  symptoms  that  are  apparently 
serious  at  the  time.  In  a  case  reported  by  Howe,""*  a  young  man  on  a 
bicycle  ran  into  a  rubbish  cart,  receiving  a  blow  from  the  shaft  just 
below  the  left  breast.  The  injury  was  apparently  so  slight  that  in  six 
days  the  effects  of  the  contusion  had  passed  and  he  was  able  to  reassume 
his  life  at  a  military  school.     Symptoms  of  strangulation  occurred 

1  British  Med.  Jour.,  1910,  ii,  1297. 

^  Surg.,  Gyncc,  and  01)s<et.,  August,  1909,  p.  154. 

'  Medical  News,  Novonihcr,  1901,  p.  S45. 


SYMPTOMS  OF  DIAPHRAGMATIC  HERNIA  403 

seven  months  later,  after  a  jumping  contest.  Autopsy  showed  the 
stomach,  transverse  and  upper  part  of  the  descending  colon,  with  the 
greater  part  of  the  omentum  within  the  pleural  cavity.  The  omentum 
was  adherent  to  the  pleura  at  the  site  of  the  contusion  of  the  chest. 

Acquired  Form. — In  the  acquired  form  the  intrusion  takes  place 
through  one  of  the  natural  openings  of  the  diaphragm  and  constitutes 
a  true  hernia  in  the  sense  that  a  hernial  sac  regularly  forms  an  investing 
membrane.  Hernia  through  the  esophageal  opening  is  most  common, 
either  to  the  right  or  the  left  side,  and  may  be  of  considerable  size. 
In  the  case  reported  by  Beckman^  one  could  introduce  the  hand  at  the 
site  of  the  esophagus.  Next  in  frequency  is  hernia  through  the  opening 
for  the  splanchnic  nerves  and  for  the  aorta. 

Symptoms. — Congenital  Form. — In  the  congenital  cases  the  symptoms 
may  a])pear  at  or  soon  after  birth  or  may  be  deferred  until  late  in 
life". 

Lacher  estimates  that  40  per  cent,  of  all  the  congenital  forms  of 
hernia  give  symptoms  during  an  extremely  early  age.  Knaggs  in  24 
cases  of  this  form  of  hernia  found  that  4  occurred  in  the  fetus,  5  in 
children  who  died  at  birth,  while  in  15  the  symptoms  first  appeared 
between  the  ages  of  six  weeks  and  sixty  years. 

In  many  instances  the  child  is  stillborn  or  dies  soon  after  birth.  In 
the  latter  instance  cyanosis  and  dyspnea  are  prominent  symptoms,  and 
the  left  chest  does  not  usually  expand  to  a  normal  degree.  Dextro- 
cardia is  usually  present,  and  death  results  within  a  few  hours. 

In  other  instances  the  child  may  survive  days  or  even  weeks  in  a 
condition  of  poor  nutrition  and  with  impaired  respiratory  powers. 
Gastric  symptoms  may  be  entirely  lacking.  These  children  frequently 
die  from  intercurrent  disease,  especially  of  a  pulmonary  nature. 

It  may  happen  that  no  symptoms  are  evident  until  late  in  life.  In 
these  cases  of  late  development  of  symptoms,  there  is  a  congenital 
defect  in  the  diaphragm  through  which  the  stomach  and  omentum  are 
apt  to  pass.  No  symptoms  are  usually  induced  by  such  a  condition 
until  the  time  arri^'es'  when  the  herniated  portions  undergo  strangula- 
tion, either  from  volvulus  or  twist,  or  from  the  engagement  of  other 
abdominal  organs  into  the  hernial  cleft  or  to  a  swelling  of  the  herniated 
portions  themselves  by  accumulation  of  gas  within  them. 

Ringrose^  reports  the  case  of  a  woman,  aged  twenty-six  years,  who 
had  never  suffered  from  indigestive  troubles  until  three  days  before 
her  death,  when  in  the  seventh  month  of  pregnancy  she  began  to  vomit 
yellow  fluid  and  complain  of  pain  in  the  upper  left  abdomen.  The 
following  day  she  miscarried  without  labor  pains  or  warning;  she  became 

1  Loc.  cit.  -  British  Mod.  Jour.,  November  26,  1910,  p.  1673. 


404  DIAPHRAGMATIC  HERNIA 

cyanotic,  vomited  blackish  fluid,  had  intestinal  pain  in  the  left  side 
under  the  costal  arch,  developed  jaundice,  and  died  after  an  illness  of 
three  days.  A  distended  stomach,  containing  3  quarts  of  blackish 
fluid,  was  found  in  the  left  chest,  reaching  as  high  as  the  second  rib. 
The  })ylorus  was  found  in  its  normal  position,  but  there  was  an  hour- 
glass constriction  where  a  portion  of  the  stomach  had  passed  through 
the  hernial  cleft  in  the  diaphragm  and  had  become  strangulated.  The 
whole  stomach  was  rotated  on  its  longitudinal  axis  so  as  to  lie  upside 
down.  One-quarter  of  the  small  intestine,  and  a  greater  part  of  the 
omentum,  had  passed  through  the  opening  and  had  compressed  the 
left  lung  against  the  vertebral  column.  The  hernial  orifice  in  the  left 
side  of  the  diaphragm  admitted  the  entire  hand,  and  was  unmistakably 
of  congenital  origin. 

In  otlier  cases  there  may  be  attacks  of  mild  and  transient  strangula- 
tion, the  patient  comjjlains  of  mild  indigestion  after  eating,  and  from 
time  to  time  of  epigastric  pain  and  efforts  at  vomiting,  although  at 
any  time,  overdistention  of  the  herniated  stomach  may  cause  sudden 
heart  failure  and  even  death.  Recovery  follows  the  spontaneous  reduc- 
tion of  the  hernia,  but  the  attacks  tend  to  become  more  frequent 
and  more  severe  until  the  time  arrives  at  which  the  herniated  portion 
becomes  entirely  strangulated. 

Fisher^  reports  the  case  of  a  man,  wiio  for  years  would  have  attacks 
of  pain  after  food,  so  severe  that  he  would  roll  on  the  floor  until  the 
pain  was  relieved  by  vomiting.  For  two  months  prior  to  his  last  illness 
the  attacks  had  been  growing  more  severe  and  more  frequent.  October 
17,  at  5  P.M.,  one  of  these  attacks  began  with  epigastric  pain  and  dis- 
tention. The  following  day  he  ^'omited  brown  fluid  and  his  pain  was 
more  severe.  The  distention  in  the  epigastrium  had  likewise  increased, 
and  a  swelling  could  be  made  out  in  the  left  hypochondrium,  feeling 
like  an  inflated  rubber  bag.  There  was  tympany  in  the  anterior  axillary 
line  as  high  as  the  sixth  rib.  He  died  at  10  p.m.,  October  19,  after  an 
illness  of  thirty  hours'  duration. 

The  autopsy  showed  free  gas  in  the  abdominal  cavity.  The  lesser 
peritoneal  cavity  was  distended  and  filled  with  thick  black  fluid,  looking 
like  altered  blood.  There  was  found  an  a])erture  in  the  diaphragm, 
two  inches  in  diameter,  to  the  left  of  the  esophageal  opening,  apparently 
of  congenital  origin,  and  the  stomach  had  been  in  the  habit  of  passing 
fr('(']>'  into  the  hernial  sac,  from  time  to  time;  and  then  after  vomiting, 
nndcrgoing  si)ontaneous  reduction.  Througii  this  opening  the  i)yloric 
{)()rti()ii  of  tlie  stomach  had  become  herniated  though  easily  reduced 
by  traction.     The  cardiac  portion,  l\'ing  in  the  abdominal  cavity,  had 

I  Lanrot,  Dox^cmbnr  8,  1897,  p.  1.'584. 


SYMPTOMS  OF  DIAPHRAGMATIC  HERNIA  405 

jHTt'orated  into  the  lesser  jXTitoiieal  sac,  and  through  the  perforation 
(lark  red  fluid  was  {nmug. 

Traumatic  Form. — In  the  traumatic  cases  the  onset  of  synij)toms  may 
directly  follow  the  accident  or  may  be  deferred  until  months  or  years 
afterward.  According  to  Lacher,  of  36  cases  of  injury  to  the  diaphragm 
that  were  not  operated  upon  immediately,  5  died  in  one  day,  10  in  a 
month,  5  in  five  years,  and  5  in  twenty  years. 

The  initial  symptoms  are  those  of  the  causal  injury,  usually  with 
considerable  degree  of  shock.  In  the  case  of  stab  wounds  or  bullet 
injur}^  pneumothorax  may  result  and  there  may  be  symptoms  of  internal 
hemorrhage  and  the  patient  may  die  from  the  injury  before  gastric 
symptoms  have  sufficient  time  to  develop.  The  diaphragmatic  wound 
rarely  in  itself  is  the  cause  for  death.  Should  the  patient  survive  the 
initial  shock  of  the  accident,  distressing  dyspnea  and  severe  epigastric 
or  thoracic  pain  are  the  chief  symptoms  observed.  The  face  is  usually 
somewhat  cyanotic,  the  breathing  shallow  and  difficult.  Vomiting 
may  occur,  or  there  may  be  ineftectual  attempts  to  vomit  and  a  desire 
but  not  an  ability  to  raise  wind.  The  symptoms  of  the  acute  onset 
are  strikingly  like  those  of  sudden  pneumothorax.  Strangulation  or 
perforation  may  supervene. 

In  the  majority  of  instances  a  gradual  improvement  takes  place  and 
the  patient  is  thought  to  have  made  a  satisfactory  recovery,  although 
there  may  remain  some  epigastric  pain  or  a  moderate  degree  of  dyspnea. 
In  other  instances  there  may  be  no  indication  of  any  digestive  trouble 
whatever  until  the  appearance  of  attacks  which  mark  the  temporary 
incarceration  of  the  herniated  organs. 

Pain  is  the  chief  symptom  and  is  often  so  excruciating  that  the  patient 
wall  roll  on  the  floor  in  agony  or  will  scream  so  that  he  may  be  heard  for 
blocks.  Dyspnea  usually  results  from  the  pressure  of  the  herniated 
viscera  on  the  heart  or  lung,  and  is  regularly  more  marked  when  the 
hernia  is  left-sided.  During  the  periods  of  most  intense  dyspnea  cyanosis 
is  usually  present.  Dyspnea  may  continue  after  the  acuteness  of  the 
attack  has  subsided,  so  that  it  becomes  more  or  less  permanent  and  may 
last  for  years,  appearing  after  exercise  or  after  the  taking  of  a  full  meal. 

Vomiting  is  usually  present  during  the  acute  exacerbations,  the 
vomited  matters  often  consisting  of  a  brownish  blood-stained  fluid. 
Hemorrhage  from  the  stomach  is  almost  invariably  present  in  severe 
attacks.  In  cases  of  torsion  or  compression  of  the  esophagus  vomiting 
is  impossible,  though  futile  attempts  to  empty  the  stomach  by  repeated 
and  painful  retching  are  not  uncommon.  Thirst  in  all  cases  is  excessive 
and  is  not  easily  assuaged. 

When  the  hernia  is  chronic  there  is  often  the  history  of  recurring 
pain  and  vomiting,  especially  after  meals,  these  symptoms  probably 


400  DIAPHRAGMATIC  HERNIA 

being  iiKliiccd  bv  ()l)structi()ii  to  the  passage  of  food  from  the  herniated 
stomach  into  the  intestine.  Some  patients  complain  of  pain  reguhirly 
occurring  when  they  rise  in  the  morning,  whicli  (hsappears  after  they 
have  been  up  and  around  for  a  time.  An  expUmation  of  this  important 
symptom  is  that  while  lying  down  the  contents  of  the  abdomen  gradu- 
ally find  their  way  into  the  chest.  The  pain  on  rising  is  caused  by  the 
crowding  of  the  bowel  into  the  opening  by  gravitation,  and  the  relief 
which  appears  after  a  time  seems  due  to  the  return  of  the  contents  to 
their  proper  position  in  the  abdomen.  The  full  feeling  of  extreme 
distention  of  the  stomach  from  gas  is  often  the  source  for  complaint 
in  the  chronic  cases.     Gastric  tetany  has  been  known  to  occur. 

8/iould  strangulation  occur,  the  symptoms  become  suddenly  intensified 
and  collapse  supervenes.  There  may  be  inability  to  swallow  liquids, 
or  there  may  be  watery  blackish  vomiting,  according  to  the  patency  of 
the  esophagus.  Symptoms  of  acute  perforation  may  occur.  Death 
usually  takes  place  within  forty-eight  hours  after  the  onset  of  strangu- 
lation symptoms. 

Acquired  Form. — The  symptoms  in  this  form  are  apt  to  appear  in 
a  series  of  minor  attacks  without  apparent  cause,  terminating  the 
sudden  onset  of  strangulation  symptoms  unless  relieved  by  timely 
intervention. 

In  a  case  reported  by  Beckman^  which  was  operated  upon  successfully 
by  W.  J.  Mayo,  the  clinical  symptoms  and  gastric  analysis  closely 
resembled  carcinoma,  although  from  the  physical  examination  a  cystic 
gall-bladder  was  diagnosticated.    The  case  is  reported  as  follows: 

Woman,  aged  forty-seven  years,  w^ho  four  years  previously  began 
to  suffer  from  sharp  severe  pain  in  the  pit  of  the  stomach  and  to 
the  left  side  one-half  hour  after  meals.  She  would  vomit  if  she  ate 
more  than  a  moderate  quantity  of  food  at  a  single  meal.  Occasionally 
she  vomited  blood,  and  food  eaten  two  or  three  days  previously.  At 
night  she  might  vomit  the  food  she  ate  at  noon.  These  symptoms 
have  grown  much  worse  the  past  year,  so  that  she  is  unable  to  keep 
food  on  her  stomach  more  than  an  hour,  has  lost  100  pounds  in  the 
past  three  years,  and  is  much  emaciated. 

On  examination  a  small  freely  movable  tumor,  the  size  of  a  lemon, 
is  palpal)le  under  the  right  costal  arch,  which  on  the  exploration  proved 
to  be  a  cystic  gall-bladder. 

Gastric  analysis  showed  total  acidity  of  5,  no  free  hydrochloric  acid. 

At  operation  by  W.  J.  Mayo  it  was  found  that  the  esophageal  oj)en- 
ing  would  admit  the  hand,  and  that  through  it  had  passed  the  entire 
.stomach,   quite  adherent  inside  the  thoracic  cavity.     The  adhesions 

'  Loc.  cit. 


DIAGNOSIS  OF  DIAPHRAGMATIC  IIEHKIA  407 

were  tied  oft*  and  the  stomaeh  was  sutured,  the  dome  to  the  marghis 
of  the  diaphragmatic  opening,  the  body  at  various  points  to  the 
parietal  peritoneum,  and  the  pylorus  and  duodenum  were  drawn  to 
the   right  side  and  held   in  place  by  sutures.     Recovery  uneventful. 

In  some  instances  the  attacks  of  temporary  incarceration  are  attended 
by  symptoms  so  slight  as  to  be  almost  passed  over  in  the  clinical  history, 
so  that  the  diagnosis  is  made  with  greater  difficulty  than  usual.  Waller^ 
reports  the  case  of  a  young  man,  aged  twenty  years,  whom  on  arrival 
he  found  dead.     From  the  family  the  following  history  was  obtained: 

Five  years  previously  a  heavy  farm  cart  passed  over  his  left  chest  and 
he  was  obliged  to  remain  in  the  hospital  for  five  weeks  in  consequence. 
At  that  time  he  ran  a  slight  evening  temperature  for  a  few  days,  although 
no  definite  lesion  could  be  discovered.  Gastric  symptoms  were  not 
recorded  in  the  history.  One  year  after  his  discharge  he  passed  an 
examination  into  a  Forester's  Lodge,  so  that  apparently  the  chest 
signs  were  not  prominent  at  that  time.  He  remained  well  until  four 
months  before  his  death,  when  he  had  a  "sick  attack,"  which  passed 
oft'  in  twenty-four  hours  without  medical  assistance.  The  morning 
before  his  death  he  was  working  in  the  fields  as  usual  and  ate  his  accus- 
tomed dinner.  In  the  afternoon  he  began  to  feel  ill  and  vomited.  His 
condition  was  not  considered  serious  enough  to  call  a  physician.  The 
following  morning  he  died  after  an  illness  of  about  eighteen  hours' 
duration. 

At  autopsy  the  left  lung  was  compressed  to  the  size  of  an  average 
spleen.  The  whole  of  the  stomach  except  the  pyloric  end  had  passed 
through  the  esophageal  opening  of  the  diaphragm,  the  aperture 
admitting  three  fingers,  was  quite  unconstricted,  but  contained  a 
large  amount  of  blackish  fluid. 

It  is  doubtful  whether  this  case  should  be  classed  among  the  trau- 
matic or  the  acquired  hernias. 

Diagnosis. ^Physical  Signs. — The  physical  signs  should  be  sufficiently 
evident  to  occasion  at  least  a  suspicion  of  the  disorder,  but  in  the  great 
majority  of  instances  the  physician  is  unprepared  for  the  emergency 
and  does  not  think  of  diaphragmatic  hernia  even  though  the  physical 
signs  taken  in  connection  with  the  clinical  history  should  be  quite 
convincing.  Of  250  cases  reported  by  Liechtenstein  a  correct  diagnosis 
was  made  in  but  five.  These  cases  were,  however,  collected  before  the 
days  of  .r-rays. 

The  chest  on  the  aflFected  side  is  usually  prominent  and  comparatively 
motionless,  the  restriction  in  its  expansion  being  more  noticeable  in 
the  lower  portion.    Litten's  phenomenon  is  regularly  absent.    Intestinal 

1  Lancet,  October  15,  1910,  p  11.35. 


408  DIAPHRAGMATIC  HERNIA 

peristalsis  communicating  writhing  movements  to  the  thoracic  wall 
were  observed  by  Holt  in  the  case  of  an  infant.  Retraction  of  the 
epigastrium  may  be  detected  and  there  may  be  a  considerable  rigidity 
of  the  upper  abdominal  wall.  In  other  cases  the  epigastrium  may  be 
unduly  prominent,  from  the  distention  of  the  cardiac  end  of  the  stomach 
that  remains  on  the  abdominal  side  of  the  hernial  orifice,  and  palpation 
may  even  detect  this  distended  portion  of  the  viscus  as  a  smooth  elastic 
tumor  not  unlike  an  inflated  rubber  bag.  Scars  from  old  wounds  of 
the  lower  thorax  are  of  much  value  as  corroborative  evidence. 

The  signs  at  the  base  of  the  chest  closely  resemble  those  due  to 
pneumothorax.  The  note  is  tympanitic  over  the  lower  section,  or  there 
may  be  an  area  of  dulness  due  to  fluid  in  the  herniated  stomach  or 
to  the  presence  of  spleen  or  omentum  below  the  area  of  tympany. 
The  note  is  more  clearly  tympanic  or  even  amphoric  after  artificial 
inflation  of  the  stomach  by  CO2  and  the  area  over  which  the  note  is 
elicited  becomes  greater.  Filling  the  stomach  with  water  may  cause 
partial  flatness  instead  of  tympany.  If  the  colon  be  part  of  the  hernia 
its  inflation  will  likewise  affect  the  tympany  in  the  chest.  Over  the 
affected  area  breath  sounds  are  distant,  and  loud  gurgling  and  tinkling 
sounds  may  be  heard.  In  some  instances  these  adventitious  sounds 
are  evidently  synchronous  with  peristalsis  rather  than  with  respira- 
tion, and  are  therefore  very  suggestive  of  the  condition,  although  some 
uncertainty  may  arise  whether  the  sounds  arise  in  the  thorax  or  are 
merely  "transferred"  from  the  abdominal  cavity.  Similar  gurgles 
may,  however,  be  heard  during  expiration  and  are  due  to  the  forcing 
of  gas  through  the  neck  of  the  herniated  organ,  whether  colon  or 
stomach,  into  the  portion  of  the  organ  that  lies  below  the  diaphragm. 
The  physical  signs  are  often  altered  remarkably  by  changes  in  the 
position  of  the  patient. 

Above  the  affected  area  the  note  may  be  hyperresonant  or  of  a  dull 
tympanitic  quality,  while  the  breath  sounds  are  but  slightly  altered 
from  the  normal.  These  are  the  signs  observed  in  cases  in  which  visceral 
encroachment  on  the  lung  has  not  been  sufficient  to  cause  it  to  be 
compressed.  When  actual  compression  of  the  lung  takes  place,  the 
note  })ecomes  progressively  dull  and  the  breathing  approaches  the 
bronchial  type.  As  the  majority  of  hernias  are  left-sided  the  heart 
is  usually  displaced  to  the  right.  Dextrocardia  is  more  easily  demon- 
strated by  .T-rays  than  by  percussion,  as  the  percussion  signs  of  the 
left  border  are  apt  to  be  obscured  by  the  neighboring  tympany. 

Convincing  evidence  of  the  stomach  or  colon  lying  in  the  thoracic 
cavity  is  aft'orded  by  the  a:-ray,  both  before  and  after  the  filling  of 
the  stomach  or  colon  by  bismuth  suspensions.  The  simplest  method 
is  perhaps  the  demonstration  that  the  colon  after  bismuth  injection 


PLATE    XI 


Right-sided  Diaphragmatic  Hernia.  Colon  in  thoracic  cavity,  with  trans- 
position of  Hver  only.  (Case  of  Dr.  Rowland  G.  Freeman;  radiologist, 
Dr.  Leanning.) 


DIAGNOSIS  OF  DIAPHRAGMATIC  HERNIA 


409 


lies  in  tiie  thoracic  cavity,  altliougli  it  is  not  in  every  case  of  hernia 
that  the  colon  participates  in  the  process,  hnt  a  plate  showing  bismuth 
in  the  colon  above  the  diaphragm  line  is  coiiclusixc  c\  idcnce  of  a  dia- 
phragmatic hernia. 


Fig 


Ascending 
colon. 


Transverse 
colon  in  chest. 


Sigmoid. 


Diaphragmatic  hernia.     Photograph  of  abdomen  after  an  enema  of  bismuth   had  been  given. 

(Carson-Huelsmann.) 

According  to  GifRn  the  most  noticeable  abnormality  is  the  existence 
of  a  curved  shadow  line  in  the  left  chest  with  the  concavity  downward. 
This  shadow  line  generally  maintains  a  typical  dome  shape  whether 
it  be  high  or  low.  The  mottled  appearance  of  lung  tissue  is  visible 
through  the  gas  contained  in  the  stomach,  a  point  of  value,  accord- 
ing to  Giffin,  in  differentiating  between  diaphragmatic  hernia  and 
eventration  in  which  this  appearance  is  not  noted  even  with  extreme 
distention  of  the  stomach. 

A  series  of  .r-ray  plates  following  a  bismuth  meal  should  afford  con- 
vincing proof  of  hernia,  if  the  stomach  be  identified  as  lying  in  a  high 
position  above  the  diaphragm.  The  upper  level  of  the  bismuth  meal 
may  be  distinctly  seen,  bounded  above  b}^  a  large  air-bubble,  the  upper 
limit  of  which  is  marked  by  the  curved  bowline  which  represents  the 
upper  wall  of  the  stomach.  These  important  points  are  well  illustrated 
by  the  study  of  the  accompanying  plates  from  Giffin,  which  merit 
careful  stud  v. 


410  DIAPHRAGMATIC  HERNIA 

A  ''paradoxical  expiratory  displacement"  has  been  observed  in  dia- 
phragmatic hernia.  During  forced  inspiration  the  diaphragm  descends 
normally  on  the  right  side  while  the  line  on  the  left  side  ascends.  Dur- 
ing forced  expiration  re^'ersed  movements  occur.  This  phenomenon  is 
said  to  be  absent  in  eventration.  By  powerful  expiratory  movements 
of  the  abdominal  wall  the  shadow  line  on  the  left  side  is  forced  high . 
into  the  chest. 

Differential  Diagnosis. — A  differential  diagnosis  between  hernia  and 
eventration  is  of  importance,  because  while  hernia  is  often  operable, 
eventration  is  beyond  the  power  of  surgery  to  repair,  and  unless  a 
diagnosis  is  made  the  patient  may  be  subjected  to  an  exploration  that 
is  futile  and  unnecessary.  Giffin  attaches  much  importance  to  the 
mottled  lung  tissue  appearing  through  the  gas-bubble  in  cases  of  hernia 
and  to  the  relative  position  of  two  curved  lines  on  the  radiographic 
plate.  "If  two  curved  shadows  be  present,  a  radiographic  or  fluoroscopic 
examination  after  distention  of  the  stomach  should  indicate  which 
line  is  stomach  and  which  diaphragm;  if  the  lower  line  be  stomach  it 
will  move  up  against  the  diaphragm  line,  and  the  pyloric  end  will  then 
unfold;  if  the  upper  line  be  stomach,  distention  upward  into  the  chest 
will  be  almost  unlimited.  If  the  bowlines  shadow  represent  both 
diaphragm  and  stomach,  distention  will  cause  merely  the  above-men- 
tioned unfolding  of  the  pars  pylorica." 

The  history  of  recurring  attacks  of  pain  and  \'omiting  after  injuries 
to  the  lower  thorax  or  abdomen  would  point  to  hernia  rather  than  to 
eventration,  but  in  spite  of  every  possible  care  a  differential  diagnosis 
may  be  at  times  quite  impossible. 

In  pneumothorax  the  physical  signs  of  extensive  involvement  of 
the  lung  are  usually  evident  above  the  area  of  t\mpay,  and  in  many 
cases  signs  of  pulmonary  disease  are  obtained  over  the  opposite  side. 
Gastric  symptoms  are  less  in  evidence,  nor  is  there  usually  the  history 
of  recurring  attacks  of  temporary  incarceration  so  commonly  elicited 
in  the  hernia  cases.  Radiograms  in  pneumothorax  usually  show  an 
unbroken  diaphragmatic  line,  whereas  in  hernia  this  line  is  often 
irregular  or  incomplete.  The  differential  diagnosis  while  simple  enough 
in  many  instances  may  be  extremely  difficult,  especially  when  the 
patient  has  recived  stab  or  bullet  wounds  in  the  chest.  In  one  case 
needling  of  the  chest  resulted  in  the  aspiration  of  brand\-  and  water 
tiiat  had  recently  been  given  to  the  patient. 

Large  basic  cavities  would  hardly  be  mistaken  for  hernia  if  sufficient 
attention  be  given  to  the  history  and  the  physical  signs.  Radiographs 
would  show  extensive  lung  involvement  surrounding  the  air  space  and 
an  unbroken  diaphragm  line  would  lie  below  the  lesion. 

Subphrenic  pyopneumothorax  usually  follows  perforation  of  a  gastric 


PLATE    XII 


June  26,  1911.  Case,  diaphragmatic  hernia,  with  the  stereoscopic  radiographs  made  of  patient 
in  the  vertical  position,  the  sternum  next  to  the  x-ray  plate,  care  being  taken  to  avoid  any  rotation 
of  the  spine  on  its  long  axis.    The  central  focus  corresponds  to  the  level  of  the  seventh  dorsal  vertebra. 

We  are  viewing  the  thorax  through  from  behind,  therefore  the  right  side  of  the  print  represents  the 
right  side  of  the  thorax.    These  prints  are  fac-simile  reproductions  of  the  original  plates. 

Note  the  position  and  outline  of  the  pericardial  shadow.  The  heart  inclines  strongly  toward  the 
right,  its  right  border  extending  a  greater  distance  to  the  right  of  the  midsternal  line  than  does  the 
left  border  to  the  left  of  the  spine. 

Both  hiluses  are  abnormally  dense,  the  left  being  markedly  enlarged.  Both  apices  are  clear,  and 
the  pulmonary  tissue  is  normal  in  all  three  right  lobes  and  in  the  upper  left  lobe. 

In  the  lower  portion  of  the  left  thorax  can  be  seen  clearly  a  curved  white  line  of  greatly  increased 
density.  The  proximal  end  of  this  line  is  opposite  the  level  of  the  spinal  juncture  of  the  eighth  rib 
on  the  left  side.  From  this  point  the  line  curves  outward  along  the  eighth  interspace  to  the  ninth  rib. 
Between  this  line  and  the  upper  border  of  the  tenth  rib  is  seen  a  dark  area  of  greatly  decreased  density, 
through  which  one  can  clearly  distinguish  branches  from  the  lower  pole  of  the  left  hilus.  The  costal 
portions  of  three  ribs  are  also  visible.    The  left  margin  of  the  pericardial  shadow  is  not  clearly  defined. 

Note  the  clear-cut  outline  of  the  dome  of  the  diaphragm  to  the  right  of  the  spine  and  compare  it 
with  the  faint,  indistinct  outline  on  the  left  of  the  spine,  which  is  to  be  seen  just  below  the  tenth  rib. 

The  unusual  appearance  of  the  lower  portion  of  the  left  thorax  attracted  our  attention  and  suggested 
strongly  the  probability  of  a  hernia  of  the  diaphragm.  A  study  of  the  stereoscopic  plates  supported 
this  suspicion,  and  it  was  deemed  important  to  establish  the  position  of  the  stomach,  for  it  seemed 
likely  that  the  dark  shadow  below  the  abnormally  placed  curved  line  was  due  to  gas  in  the  stomach. 
With  this  end  in  view  an  emulsion  of  subcarbonate  of  bismuth  and  acacia  was  given  the  patient  by 
mouth  and  a  second  set  of  plates  made  immediately,  the  patient  being  in  the  vertical  position 
(Plate  XIII).      (Giffin.) 


PLATE    XIII 


Radiographed  immediately  after  the  ingestion  of  bismuth  suboarbonate  emulsion.  Compare  with 
Plate  XII. 

Note  the  line  of  demarcation  between  the  white  dense  area  and  the  dark  area  lying  above  it.  The 
white  shadow  represents  bismuth  in  the  stomach,  the  upper  border  of  the  shadow  representing  the 
surface  level  of  the  emulsion.  Above  the  bismuth  is  seen  the  gas-bubble  of  the  stomach.  This  is 
limited  above  by  the  wall  of  the  stomach,  which  we  recognize  as  the  curved  line  described  in  Plate 
XII.  Note  the  faint  outline  of  the  bismuth  lining  the  esophagus.  This  can  be  traced  upward  to 
the  limit  of  the  plate.  Plates  XII  and  XIII,  together  with  the  historj-,  confirmed  the  diagnosis  of 
hernia  of  the  diaphragm. 

Important  diagnostic  points  demonstrated  by  the  radiographs.  Plates  XII  and  XIII:  (1)  the  presence 
of  a  dark  circumscribed  shadow  situated  above  the  indistinct  outline  of  the  diaphragm  on  the  left  side 
and  bounded  above  by  a  curved  dense  band  which  does  not  maintain  the  dome  shape  typical  of  the 
normal  diaphragm  line,  and  limited  mesially  by  the  left  border  of  the  heart,  which  is  displaced  strongly 
to  the  right;  (2)  the  presence  of  the  shadows  of  the  lower  branches  of  the  left  hilus  showing  through 
rarefied  area;  (3)  the  location  of  the  stomach  and  its  great  bubble  by  bismuth  ingestion  method. 
(Giffin.) 


RARE   FORMS  OF   1)1  ARII RAOM AT IC   IIERKJA  411 

or  (liiodeiial  ulcer.  The  history  of  the  case,  leukocytosis,  with  rehitixe 
increase  in  the  polynuclears,  and  the  (leinonstratiou  of  a  hi<i;h  (haj)hraj^ni 
line  lyin<f  above  the  lesion,  are  the  chief  points  to  he  relied  upon  tor 
diagnosis. 

Prognosis. — The  prognosis  is  exceedingly  grave.  Death  may  result 
early  in  infancy  as  described  in  the  symptomatology  of  the  congenital 
form,  or  delayed  until  adult  years.  Traumatic  cases  may  die  of  shock 
from  the  causal  injury  or  a  fatal  issue  may  not  result  until  years  after- 
ward from  strangulation  of  the  herniated  viscera.  Perforation  may 
be  the  terminal  event.  The  only  hope  lies  in  the  early  diagnosis  of 
the  condition  before  the  appearance  of  urgent  strangulation  symptoms 
and  in  closing  the  cleft  surgically.  This  has  of  late  been  done  with 
brilliant  results.  When  strangulation  symptoms  appear  it  is  improbable 
that  surgery  can  prove  of  much  avail,  although  an  emergency  operation 
would  naturall}^  be  indicated. 

Treatment. — The  treatment  of  diaphragmatic  hernia  is  essentially 
surgical.  An  attempt  should  be  made  to  replace  the  herniated  viscera 
and  to  close  the  rent.  If  the  orifice  be  small,  the  edges  may  be  sew^ed 
together;  if  larger,  the  stomach  may  be  sutured  to  the  edges  of  the 
aperture  so  as  to  close  the  opening.  Serious  radical  defects,  such  as 
congenital  absence  of  half  the  diaphragm,  are  of  course  difficult  or 
impossible  of  repair.  Two  exploratory  routes  have  been  recommended, 
a  thoracic  and  an  abdominal.  Those  who  favor  the  thoracic  incision 
claim  that  the  diaphragmatic  rent  is  more  accessible  for  suturing,  and 
that  by  the  entrance  of  air  into  the  pleural  cavity  the  negative  or  suction 
power  of  the  thorax  is  abolished,  so  that  replacement  of  the  viscera 
through  the  cleft  is  easily  accomplished. 

The  advocates  of  the  abdominal  incision  are  of  the  opinion  that  the 
aspiration  or  suction  powder  of  the  thorax  is  rarely  sufficient  to  prevent 
reduction  by  a  reasonable  amount  of  traction,  and  that  strangulations 
are  better  seen  and  cared  for  by  abdominal  incisions  than  by  the  thoracic 
route.  If  at  any  time  in  the  operation  it  seems  advisable,  a  thoracic 
incision  may  be  made  and  the  surgical  work  done  b}^  a  combination 
method. 

Rare  Forms  of  Diaphragmatic  Hernia. — A  partial  form  of  diaphrag- 
matic hernia  occurs  when  a  pouch-like  projection  of  the  stomach  wall 
enters  the  diaphragmatic  cleft.  Only  two  instances  of  this  partial  or 
so-called  "Richter's  hernia"  have  been  recorded,  and  in  neither  case 
is  there  any  clinical  history.  One  recorded  by  Andrew  is  quoted  by 
Knaggs.^ 

"  A  dome-shaped  pouch  of  the  diaphragm  existed  immediately  to  the 

1  Lancet,  August  6,  1904. 


412 


DIAPHRAGMATIC  HERNIA 


left  of  the  esophageal  opening  and  into  it  a  ])orti()n  of  the  cardiac  end 
of  the  stomach  measuring  \ertically  al)out  one  inch  was  drawn.  The 
hernia  couhi  easily  be  pulled  down  and  the  part  of  the  stomach  wall 
that  lay  against  the  neck  of  the  pouch  was  thickened." 

In  the  other  instance  a  pouch  formed  from  the  greater  curvature 
had  passed  through  an  aperture  in  the  diaphragm  and  had  become 
strangulated. 

Fig.   so 


Stomach  showing  diverticuluin  of  cardiac  end  in  the  pouch  of  the  iliaphiagin.     (From  the 
Lancet,  March  21,  1903.) 


Diaphragmatic  Hernia  with  Gastroptosis. — Examples  have  occurred 
of  extreme  degrees  of  visceroptosis  in  which,  owing  to  the  descent  of 
the  diaphragm  by  the  giving  away  of  its  support,  the  diaphragm  at 
the  seat  of  the  esophageal  opening  sags  downward  to  a  greater  extent 
than  can  be  overcome  by  a  downward  traction  of  the  esophagus,  so 
that  as  the  diaphragm  descends  the  esophagus  pulls  up  the  cardiac 
orifice  of  the  stomach  to  such  an  extent  that  this  portion  of  the  organ 
lies  within  the  thorax  and  above  the  level  of  the  esophageal  aperture. 
Whether  or  not  such  a  condition  would  give  rise  to  clinical  symptoms 
is  a  matter  of  conjecture.  The  writer  has  encountered  one  instance 
of  esophageal  diverticulum  with  the  characteristic  symptoms  of  cardio- 
spasm, in  which  obstruction  to  the  passage  of  food  from  the  esophagus 
to  the  stomach  was  apparently  caused  by  a  redundancy  of  mucous 
membrane  at  the  mouth  of  the  sac,  causing  a  valve-like  closure  of  the 
aperture.  Permanent  cure  was  eft'ected  by  the  Mikulicz's  operation 
done  by  Dr.  Erdman,  consisting  in  the  opening  of  the  stomach  and 


EVENTRATION  OF  THE  DIAPHRAGM 


413 


stretching  the  esophageal  orifice  of  the  diaphragm  by  forcible  dilatation 
from  below.  It  is  not  improbable  that  this  case  is  an  example  of  this 
form  of  hernia. 


Fig.  81 


'\ormallu  abdom 
stage  of  ucsoph 


Muscle  of  diaph. 


An  example  of  diaphragmatic  hernia  of  the  stomach  in  a  case  of  ptosis.    (From  the  Proceedings  of  the 
Anatomical  Society  of  Great  Britain  and  Ireland,  and  published  in  the  Lancet,  March  7,  1903.) 


EVENTRATION    OF    THE   DIAPHRAGM 

The  essential  lesion  in  eventration  is  the  thinning  and  consequently 
weakening  of  the  diaphragm,  almost  invariably  on  the  left  side  only, 
so  that  yielding  to  intra-abdominal  pressure  it  bulges  upward  to  form 
a  sac  into  which  one  or  more  of  the  abdominal  viscera,  particularly 
the  stomach,  may  enter.  The  condition  is  quite  distinct  from  diaphrag- 
matic hernia,  as  there  is  no  solution  of  continuity  in  the  diaphragm, 
and  the  dislocated  viscera  are  covered  by  a  true  sac  consisting  of  the 
thin  and  weakened  dome  of  the  diaphragm  covered  on  each  side  by 
parietal  peritoneum.  The  process  in  the  majority  of  the  recorded 
instances  is  evidently  congenital;  the  muscular  fibers  are  scattered  and 
in  places  absent,  so  that  the  diaphragm  is  thinned  and  often  trans- 
lucent. Lack  of  development  of  the  left  lung  has  complicated  a  number 
of  the  recorded  cases,  and  this  hypoplasia  of  the  lung  points  toward 
the  congenital  origin  of  the  lesion. 

In  Sailer's  case^  the  left  lung  was  half  its  normal  size.  Doering^ 
reports  a  case  in  which  the  left  lung  was  small,  but  consisted  of  three 


1  Amer.  Jour.  Med.  Sci.,  1905,  cxxix,  6S9. 
"  Deutsch.  Archiv  klin.  Med.,  1902,  Ixxii,  407. 


414 


EVENTRATION   OF   THE  DIAPHRAGM 


lobes.  Lawrence^  describes  an  autopsy  where  the  diaphragm  on  the 
left  side  reached  the  second  rib,  forming  a  sac  which  contained  a  greatly 
dilated  stomach.    The  left  kmg  was  reduced  to  the  size  of  a  fist. 


Fig.  82 


1 

1 

■i 

1 

This  skiagram  was  taken  with  tho  patient's  back  to  the  plate.  It  i.s,  therefore,  as  if  th<'  patient  were 
standing  with  hi.s  bark  toward  the  spectator.  On  the  right  side  is  .seen  the  heart,  and  below  that  tlic 
eonvex  upper  surface  of  the  liver,  indicating  the  position  of  the  right  half  of  the  diaphragm.  On  the 
left  side  there  is,  next  to  the  spinal  colunm,  a  narrow  band  of  shadow  indicating  the  left  border  of  the 
heart.  Then  arising  from  the  vertebral  end  of  the  seventh  rib,  arching  to  the  left  and  upward  as  far 
a.s  the  fifth  rib  and  axillary  line,  there  is  a  convex  shadow  indicating  the  position  of  the  left  half  of  the 
tliaphragm.  The  large  dark  mass  just  below  this  was  foimd  at  the  autopsy  to  be  a  huge  coaguluin  of 
milk  lying  in  the  stomach.  Below  this  the  attachment  of  the  diaphragm  can  be  .seen,  represented  by 
a  broader  line  convex  on  the  upper  surface,  and  below  this  and  to  the  left  of  the  vertebral  column  a 
lighter  .shadow,  indicating  the  po.sition  of  the  spleen.    (Sailer  and  Hhein,  radiograph  by  G.  E.  Pfahler.) 

K\cntration  may  be  acquired  during  the  achilt  life  by  atrophy  or 
degeneration  of  the  muscuhir  fibers  of  the  diaphragm  or  by  ])aralysis 
of  the  phrenic  nerve.  W idenman'^  reports  a  case  of  eventration  in  which 
the  diaiinosis  was  satisfactorih"  made  In-  the  .r-ravs.     Tlie  left  side  of 


'  Lancet,  1852,  ii,  Wll . 


■^  licrlin.  klin.  Wocli..   i'lOi,  ii,  270. 


VOLVULUS  415 

the  diaphragm  was  very  high  and  the  stomach  hiy  below  the  diaphrag- 
matic shadow.  The  patient  died  a  year  afterward  of  cancer  of  the 
tongue  (reported  by  Glaser),  and  at  the  autopsy  there  was  found  a 
fatty  degeneration  of  the  muscular  fibers  of  the  diaphragm  caused 
by  a  pseudohypertrophic  lipomatosis.  Stockton'  reported  a  case  of 
paralysis  of  the  phrenic  nerve  in  which  there  was  a  high  position 
of  the  diaphragm  and  tympany  in  the  lower  portion  of  the  left 
thorax.  The  patient  made  a  rapid  recovery,  indicating  that  the  lesion 
was  transient  and  not  congenital.  The  disease  has  been  found  in  the 
fetus  and  the  newborn  infant.  In  the  remaining  cases  the  ages  range 
from  nineteen  to  seventy-five. 

Symptoms. — Xo  characteristic  symptoms  were  present  in  any  of 
the  recorded  cases. 

Physical  Signs. — The  physical  signs  closely  resemble  those  of  dia- 
phragmatic hernia,  so  that  a  differentiation  is  often  made  with  extreme 
difficulty.  Tympany  is  present  in  the  lower  portion  of  the  right  chest, 
with  feeble  or  absent  breath  sounds.  Over  this  portion  bubbling, 
gurgling,  and  splashing  sounds  are  heard,  especially  after  the  patient 
has  swallowed  water.  The  heart  is  almost  regularly  displaced  to  the 
right.  Retraction  of  the  epigastrium  and  rigidity  of  the  upper  abdominal 
wall  do  not  occur.  The  diagnosis  can  only  be  made  with  certainty'  by 
the  .T-ray.  Radiographic  plates  show  a  high  unbroken  diaphragmatic 
line  overlying  the  boundary  of  a  distended  stomach.  (See  illustration 
from  Sailer.)  The  differences  between  the  radiographs  of  eventration 
and  diaphragmatic  hernia  are  given  in  full  under  Diaphragmatic 
Hernia. 

Treatment. — There  is  no  treatment,  medical  or  surgical,  for  the 
disease.  It  is  this  that  makes  it  important  for  us  to  differentiate 
eventration  from  diaphragmatic  hernia. 


VOLVULUS 

Volvulus  of  the  stomach  consists  in  the  abnormal  rotation  of  that 
organ  on  one  or  more  of  its  axes,  so  that  one  or  both  of  its  orifices 
become  occluded.  We  recognize  a  partial  and  a  complete  form.  In 
the  partial  volvulus,  one  orifice  alone  is  occluded,  more  frequently  the 
pylorus.  It  is  probable  that  in  many  cases  the  partial  volvulus  precedes 
the  complete  form,  the  pyloric  portion  being  first  occluded,  while  the 
cardiac  orifice  remains  patent.  This  explains  the  occurrence  of  vomiting 
in  the  earlier  stages  and  also  the  possibility  of  passing  a  tube  into  the 

1  Buffalo  MofUcal  .Toiinial,  1.S98,  xcix,  97. 


416  VOLVULUS 

stomach  and  successfully  performing  lavage.  When  by  reason  of  an 
increased  rotation  of  the  stomach,  the  cardiac  orifice  becomes  also 
twisted  to  the  point  of  occlusion,  the  volvulus  then  becomes  complete, 
so  that  neither  vomiting  nor  the  passage  of  a  tube  into  the  stomach 
becomes  possible.  The  rotation  usually  occurs  on  the  long  axis  of  the 
stomach,  which  passes  from  the  cardia  to  the  pylorus. 

Mechanism  of  Volvulus. — The  rotation  around  the  long  axis  is 
usually'  from  below,  forward,  and  upward,  being  aptly  compared  to  the 
motion  of  the  spokes  of  a  receding  wheel.  This  is  known  as  the  anterior 
volvulus,  and  it  is  far  more  common  than  the  posterior  form,  in  which 
rotation  occurs  from  below,  backward,  and  upward,  following  the  line 
of  motion  of  the  spokes  of  an  advancing  wheel.  The  cause  of  the 
increased  frequency  of  the  anterior  form  is,  that  it  is  an  accentuation 
of  the  normal  position  of  the  stomach  when  it  is  distended.  Inflation 
of  the  normal  stomach  frequently  causes  the  organ  to  rotate  on  its 
cardiopyloric  axis,  so  that  the  lower  curvature  passes  forward  and 
upward,  while  the  lesser  curvature  passes  downward  and  backward. 

Simmons^  examined  post  mortem  50  bodies  of  infants  in  which  the 
stomach  had  been  distended,  and  found  that  in  40  the  lower  curvature 
was  directed  forward,  and  the  posterior  wall  was  directed  downward, 
so  that  it  became  the  most  dependent  portion  of  the  organ.  He  found, 
moreover,  that  the  greater  the  amount  of  distention  in  the  transverse 
colon,  the  more  pronounced  was  the  rotation  of  the  stomach. 

It  is  believed  by  many  that  the  anterior  form  of  volvulus  is  favored 
by  the  natural  lines  of  peristalsis,  while  the  posterior  form  occurs  only 
in  cases  in  which  a  reversed  peristalsis  has  occurred.  The  term  volvulus 
peristalticus  has  therefore  been  applied  by  some  authors  to  the  anterior 
form  (i.  e.,  the  "retreating  wheel  type"),  while  the  term  volvulus  anti- 
peristalticus  has  been  applied  by  others,  as  Delangre  and  Neumann, 
to  the  posterior  or  "advancing  wheel  type."  These  terms,  however, 
are  but  rarely  employed. 

If  the  gastrocolic  omentum  is  of  normal  length  and  density,  the 
transverse  colon  is  usually  dragged  up  by  the  volvulus  so  as  to  lie  above 
the  stomach,  being  frequently  compressed  between  the  stomach  and  the 
liver.  As  the  stomach  lies  in  this  form  of  volvulus  below  the  colon, 
the  term  infracolic  volvulus  is  frequently  employed  by  the  German 
writers.  If,  however,  the  gastrocolic  omentum  is  unusually  long  and 
relaxed,  or  if  the  volvulus  is  not  of  an  extreme  degree,  the  position  of 
the  colon  is  unaltered  and  it  occupies  its  normal  position  beneath  the 
stomach.     As  the  stomach  lies  thus  above  the  colon,  the  term  supra- 

*  Ueber  Form  uiid  IjUKc  dos  Masons  iint.er  normalen  und  abiKinnalen  Bedingungen 
mit  zahlreichen  photographisohon  Aufiiahnicn  an  Loichcn.  Jena  ((J.  Fischer),  1907. 


MECHANISM  OF   VOLVULUS  417 

colic  volvulus  is  used  to  designate  these  cases.  The  infracolic  form  is 
more  common  in  the  cases  of  volvulus  in  which  rotation  occurs  about 
the  long  axis  of  the  stomach,  while  the  supracolic  form  is  more  frequent 
in  those  cases  in  which  the  rotation  occurs  about  anteroposterior,  or  a 
vertical  axis. 

Direction  of  Rotation. — Anterior  volvulus  about  the  long  axis  of  the 
stomach  is  the  ordinary  form  of  volvulus  associated  with  diaphragmatic 
hernia,  and  with  non-malignant  tumors  of  the  stomach. 

Rotation  of  the  stomach  about  its  vertical  axis  is  much  less  frequent. 
The  usual  line  of  rotation  is  "contra  clock-wise,"  when  viewed  from 
the  head  of  the  patient,  the  pyloric  portion  of  revolving  forward 
and  from  right  to  left.  This  form  is  almost  exclusively  a  complica- 
tion of  hour-glass  contraction  of  the  stomach.  (Cases  of  Langerhans, 
Mazzotti,  Saake.) 

Rotation  about  the  vertical  axis,  in  a  "clock-wise"  direction  in 
which  the  pyloric  portion  moves  backward  and  from  right  to  left  has 
occurred  only  in  one  known  case  (Berti^-  It  may  be  said,  however, 
that  the  descriptions  of  many  of  the  cases  of  volvulus  are  either  so 
involved,  or  so  inadequate,  that  it  is  frequently  impossible  to  determine 
with  any  certainty  the  exact  lines  of  rotation,  especially  as  in  some 
instances  rotation  on  several  axes  have  occurred  in  the  same  case. 

Rotation  about  an  anteroposterior  axis  is  the  rarest  form,  and  but 
one  case  (Streit^)  is  recorded.  In  this  instance  the  stomach  twisted 
itself  on  its  anteroposterior  axis,  "contra  clock-wise,"  the  pyloric 
portion  revolving  downward  and  from  right  to  left. 

The  Degree  of  Rotation  Varies. — It  is  very  probable  that  slight  degrees 
of  volvulus  occur,  causing  temporary  pain  distention  and  vomiting, 
and  that  the  emptying  of  the  stomach  by  the  emesis  is  followed  by 
a  spontaneous  reduction  to  the  normal  position.  In  these  cases 
the  volvulus  can  be  partial,  involving  the  pyloric  orifice,  while  the 
cardiac  orifice  remains  patent.  While  in  many  of  these  cases  spon- 
taneous reduction  occurs,  others  undergo  a  greater  degree  of  torsion 
and  produce  the  complete  form  from  which  spontaneous  recovery  is 
practically  impossible. 

In  the  majority  of  developed  cases  the  volvulus  is  one  of  180  degrees, 
so  that  the  stomach  lies  completely  upside  down. 

In  rarer  cases  more  extreme  degrees  have  occurred.  PendF  reports 
a  case  in  which  rotation  of  270  degrees  occurred  on  the  longitudinal 
axis,  while  in  Berti's  case  a  double  twist  occurred. 

1  Gaz.  med.  ital.  prov.  Venete,  Padova,  1866,  Bd.  ix,  pp.  139  to  141. 
-  Amer.  Jour.  Med.  Sci.,  1906,  cxxxi,  967. 
3  Wien.  klin.  Woch.,  1904,  No.  17,  p.  476. 
27 


418  VOLVULUS 

Berti's'  case  is  as  follows:  Female,  aged  sixty  years,  began  two  hours 
after  a  hearty  dinner  with  severe  pains  in  the  stomach  and  vomiting, 
followed  by  abdominal  distention.  The  case  was  seen  twenty-two  hours 
afterward  in  profound  collapse. 

Aniopsy. — The  distended  stomach  occupied  nearly  the  entire  ab- 
dominal cavity,  and  had  undergone  a  double  turn  about  its  longitudinal 
axis,  occluding  both  orifices,  and  by  the  extreme  torsion  bringing  the 
pylorus  and  cardia  into  juxtaposition.  Two  complete  turns  from  right 
to  left  were  required  to  reduce  the  volvulus. 

The  transverse  colon  was  compressed  between  the  stomach  and 
liver,  while  the  spleen  and  pancreas  were  displaced  together  into  the 
pelvis.  The  spleen  had  undergone  two  revolutions  on  its  axis  from 
left  to  right. 

Effect  of  Volvulus. — The  effect  of  volvulus  upon  the  stomach  is 
practically  that  of  strangulation.  The  stomach  becomes  congested, 
its  walls  thickened  and  edematous.  In  the  majority  of  instances  the 
whole  organ  is  covered  by  the  omentum,  which  has  become  fixed  by 
recent  adhesions.  There  is  great  distention,  the  stomach  often  appar- 
ently occupying  the  entire  abdominal  cavity.  This  is  due  to  the  pour- 
ing out  of  fluid  into  the  cavity  of  the  stomach,  usually  to  the  amount 
of  several  liters.  In  Wiesinger's  case  4  liters  were  evacuated  by  aspir- 
ation before  the  organ  could  be  replaced,  while  amounts  of  3  liters 
have  been  frequently  encountered.  The  fluid  is  usually  dark  brown  in 
color,  from  the  presence  of  altered  blood;  more  rarely  greenish  in  tint.^ 

In  Pendl's  case,  lactic  acid  was  present,  with  an  absence  of 
hydrochloric  acid. 

In  Cordier's^  patient  the  stomach  was  filled  with  gas  and  offensive 
material,  fecal  in  character.  The  matters  vomited  during  life  had  been 
distinctly  feculent.  As  in  this  case  total  and  complete  volvulus  had 
occurred,  complicating  a  diaphragmatic  hernia;  no  logical  rea.son  for 
the  fecal  nature  of  the  fluid  can  be  given. 

The  mucous  membrane  of  the  stomach  is  congested  and  shows  mul- 
tiple punctate  hemorrhages;  in  some  instances  the  mucous  membrane 
is  of  a  dark  brown  color,  as  if  it  had  been  painted  by  an  escharotic. 

Erosion  of  larger  or  smaller  areas  of  mucous  membrane  may  occur, 
or  even  areas  of  gangrene.  Death  usually  results,  however,  before 
gangrene  becomes  marked. 

Perforation  of  the  stomach  may  occur  either  from  traumatism  at  the 
time  of  the  volvulus  or  later  from  the  perforation  of  softened  necrotic 

'  Gaz.  med.  ifal.  prov.  Vcnete,  Padova,  1866,  Bd.  ix,  pp.  139  to  141. 
'  Xord  Mod.  Ark,  Stockholm,  1897,  X.  F.,  liand  viii,  No.  19. 
'  Annals  of  Surpery,  September,  1897,  p.  3.53. 


ETIOLOGY  OF   VOLVULUS  419 

areas.  As  an  example  of  i)erf()rati<)ii  from  rupture  may  be  cited  the 
case  of  Collischon/  who  died  with  symptoms  of  a  high-seated  obstruc- 
tion. Autopsy  showed  the  liver  displaced  downward,  lying  in  the  right 
lower  section  of  the  abdomen.  The  lesser  cur^•ature  of  the  stomach 
was  adherent  in  its  middle  to  the  under  surface  of  the  left  lobe  of  the 
liver,  and  had  been  dragged  downward  and  forward,  producing  a  vol- 
vulus of  the  long  axis,  with  a  tear  of  the  stomach  wall  at  the  site  of 
the  adhesion. 

Peritonitis  ma\'  occur  without  perforation,  and  may  cither  be  localized 
or  general.  In  volvulus  complicating  diaphragmatic  hernia,  pleurisy 
and  septic  pneumonia  may  result. 

Torsion  and  injury  to  other  abdominal  viscera  may  occur  at  the  time 
of  volvulus.     A  case  is  reported  by  Wilke.- 

There  may  be  tears  in  the  lesser  omentum  (Berg),  rupture  of  the 
splenophrenic  ligament,''  or  even  complete  separation  of  the  entire 
greater  omentimi. 

The  spleen  may  be  ruptured  either  by  traction  on  or  torsion  of  the 
gastrosplenic  ligament,^  or  it  may  be  tAvisted,  as  in  Berti's'^  case,  upon 
its  axis. 

Etiology. — It  is  convenient  in  the  description  of  the  etiology  of 
volvulus  to  divide  the  cases  into  five  clinical  groups,  and  to  describe 
each  type  separately. 

I.  Volvulus  and  Diaphragmatic  Hernia. — Diaphragmatic  hernia  has 
been  elsewhere  described,  so  that  in  this  connection  only  the  mode  of 
origin  of  the  complicating  volvulus  M'ill  be  given. 

Volvulus  complicating  diaphragmatic  hernia  may  occur  in  one  of 
two  ways,  causing  either  a  partial  or  a  complete  occlusion. 

In  the  partial  form  the  middle  or  the  pyloric  region  of  the  stomach 
passes  into  the  thoracic  cavity  through  the  hernial  cleft,  leaving  the 
fundus  and  cardiac  portion  on  the  abdominal  side, of  the  diaphragm. 
As  the  hernial  orifice  is  usually  at  or  near  the  esophageal  opening  the 
entrant  portions  have  to  rotate  upAvard  and  to  the  left,  so  that  the 
pylorus  comes  to  lie  near  the  cardiac  orifice,  producing  thus  a  rotation 
about  the  anteroposterior  axis.  The  pylorus  becomes  occluded,  but  the 
cardiac  orifice  is  patent. 

In  many  of  these  cases  the  herniated  portion  undergoes  no  change 
and  can  be  easily  withdrawn,  while  the  cardiac  portion  within  the 
abdominal  cavity  suffers  from  the  effects  of  strangulation. 

1  Inaiig.  Dissert., "Kiel,  1888. 

2  Miinch.  med.  Woch.,  1907,  liv,  No.  20,  p.  969. 

3  Dini,  quoted  by  Payer,  Mitteil.  a.  d.  Grenzg.  d.  Med.  ii.  Chir.,  Band  xx,  Heft  4. 
^  Borchardt,  Arch.  f.  klin.  Chir.,  Band  Ixxiv,  Heft  2. 

^  Loc.  cit. 


420  VOLVULUS 

In  the  second  variety  the  volvulus  is  complete,  both  orifices  being 
occluded.  Through  the  diaphragmatic  opening,  more  or  less  of  the 
stomach  passes  with  the  greater  curvature  uppermost;  the  larger  the 
opening  the  greater  the  entrant  portion  and  the  more  pronounced  the 
degree  of  volvulus.  In  many  cases  the  whole  stomach  has  been  found 
in  the  hernial  sac,  rotated  on  its  long  axis.  In  these  cases  it  is  generally 
supposed  that  the  greater  omentum  is  the  first  to  enter,  dragging  after 
it  the  greater  curvature  and  then  the  rest  of  the  stomach. 

Such  an  instance  is  given  by  ^McClosky.^  A  woman,  aged  twenty- 
two  years,  entered  the  hospital  complaining  of  vomiting,  pain  in  the 
left  chest  and  back,  passed  into  collapse,  and  died.  Duration  of  illness 
two  days.  Autopsy  showed  a  diaphragmatic  hernia  of  the  left  side, 
consisting  of  the  entire  stomach,  first  part  of  the  duodenum,  omentum, 
spleen,  and  part  of  the  small  intestine.  The  greater  curvature  was 
uppermost.  The  stomach  was  dilated  and  contained  dark  red  bloody 
fluid;  its  mucous  membrane  was  congested  and  eroded  in  places,  but 
was  not  gangrenous.  The  heart  was  displaced  to  the  right.  The  left 
lung  considerably  pushed  upward  against  the  clavicle,  occupied  only 
the  supra-  and  infraclavicular  regions. 

II.  Volvulus  and  Tumors. — Tumors  of  the  stomach  may  cause  volvulus 
by  reason  of  their  weight,  provided  that  they  are  situated  near  the  lesser 
curvature  and  are  not  adherent  to  neighboring  parts.  Sarcoma  and 
carcinoma  are  not  commonly  the  cause  for  such  displacement,  owing 
to  their  tendency  to  form  adhesions  before  they  arrive  at  the  requisite 
size  and  weight;  whereas,  the  benign  tumors  fibroma  and  fibromyoma 
often  grow  to  a  weight  sufficient  to  cause  tilting  before  the  fixation  of 
the  stomach  by  adhesion  occurs. 

Kaufmann^  describes  a  case  in  which  a  fibromyoma  weighing  2325 
grams,  attached  to  the  lesser  curvature,  had  caused  a  voK'ulus  with  a 
descent  of  the  stomach  so  that  it  was  mistaken  for  a  tumor  of  the  ovary. 
In  this  case  death  resulted  from  strangulation  symptoms,  although 
in  other  cases  the  axial  torsion  has  been  so  gradual  and  incomplete 
that  characteristic  clinical  symptoms  have  been  conspicuously  absent. 

In  a  patient  of  v.  Hacker''  a  fibromyoma  the  size  of  a  man's  head, 
and  attached  to  the  lesser  curvature,  had  produced  a  i)artial  incomplete 
volvulus,  while  in  Erlach's^  case  a  myoma  weighing  five  and  a  half 
kilos  was  removed  by  operation,  relieving  a  similar  torsion  of  the 
stomach.     In  neither  of  these  cases  were  gastric  symptoms  marked. 

'  Lancet,,  May  4,  1895. 

2  Lehrbuch  der  speziellen  Pathologischen  Anatomie,  1907,  p.  421, 

3  Wieii.  klin.  Woch.,  1900,  No.  6,  p.  146. 
'  Ibid.,  1895,  No.  15,  p.  272. 


ETIOLOGY  OF  VOLVULJ'S  421 

III.  Volvulus  and  Hour-glass  Stomach. — Volvulus  complicating  hour- 
glass contraction  of  the  stomach  has  occurred  in  a  small  number  of 
cases.  The  torsion  is  regularly  partial  and  involves  the  portion  of  the 
stomach  between  the  pylorus  and  the  constriction.  Its  occurrence 
is  favored  by  the  presence  of  single  bands  of  adhesions  at  the  point 
either  of  the  constriction  or  of  the  pylorus  so  as  to  form  a  fixed  point. 

An  example  of  this  form  is  given  by  Langerhans.^  A  woman,  aged 
forty-seven  years,  who  for  years  had  suffered  from  serious  stomach 
trouble,  was  suddenly  seized  by  vomiting  and  severe  abdominal  pain. 
Upon  her  entrance  to  the  hospital,  with  the  diagnosis  of  benign  pyloric 
stenosis,  the  stomach  was  repeatedly  washed,  each  time  showing  the 
presence  of  blood  in  the  stomach  contents.  Extreme  thirst,  anuria, 
and  finally  tetany  preceded  the  fatal  issue. 

Autopsy  revealed  a  thick  band-like  adhesion  proceeding  from  the 
lesser  curvature,  passing  to  the  anterior  abdominal  wall  in  the  left 
parasternal  line,  causing  a  constriction  of  the  stomach  just  sufficient 
to  admit  the  passage  of  one  finger. 

The  volvulus  being  partial  and  the  cardiac  orifice  patent,  the  swallow- 
ing of  food,  vomiting,  and  the  performance  of  lavage  were  all  possible, 

IV.  Volvulus  and  Trauma.^ — Volvulus  may  be  caused  by  the  traction  on 
the  stomach  by  sudden  or  traumatic  displacement  downward  of  other 
abdominal  organs,  especially  the  liver  and  spleen. 

CoUishon's  case  has  been  previously  described  in  which  the  liver  was 
suddenly  displaced  downward,  dragging  after  it  the  stomach  and  causing 
a  rotation  on  the  long  axis  by  reason  of  adhesions  between  the  under 
surface  of  the  left  lobe  and  the  middle  of  the  lesser  curvature,  and 
causing  a  tearing  of  the  gastric  wall  at  the  site  of  the  adhesion. 

Dini^  reports  a  case  of  a  peasant  woman,  aged  forty-two  years,  who 
for  a  long  time  had  suffered  from  pain  in  the  stomach,  which  was 
interrupted  by  long  intervals  of  freedom.  One  day,  after  eating,  she 
worked  in  a  bent-over  position  and  experienced  a  sudden  pain  in  the 
stomach,  more  severe  than  she  ever  had  before,  and  began  to  vomit. 
She  entered  the  hospital  in  collapse  and  died  on  the  fourth  day  of  her 
illness. 

Autopsy. — An  enlarged  spleen  lay  behind  the  symphysis;  the  spleno- 
phrenic  ligament  was  torn  across.  By  traction  on  the  gastrosplenic 
ligament  the  cardiac  portion  of  the  stomach  was  drawn  downward, 
resulting  in  an  anterior  volvulus. 

V.  Idiopathic  Cases.^ — There  is  a  group  in  which  no  one  of  the  above- 
mentioned  causes  can  be  assigned,  and  to  which  the  unsatisfactory 

1  Virchow's  Arch.,  1888,  cxi,  387. 

2  Quoted  by  Payer,  Mitteil.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  Band  xx,  Heft  4. 


422  VOLVULUS 

name  of  i(lio])athic  volvulus  is  given.  In  the  majority  of  these  cases 
the  symptoms  appear  after  a  full  meal,  showing  that  distention  of 
the  stomach  has  something  to  do  with  the  reactions. 

In  other  cases  there  is  a  history  of  some  distinct  traumatism,  either 
a  fall  or  a  blow  on  the  stomach. 

Payer's  case^  is  thus  reported.  A  male,  aged  fifty-nine  years,  fell 
from  a  ladder  an  hour  and  a  half  after  dinner,  landing  on  his  feet  with 
a  very  considerable  jar,  and  immediately  felt  a  terrible  pressure  in  the 
middle  of  his  stomach  and  over  his  heart.  He  passed  into  collapse 
and  was  admitted  into  the  hospital  an  hour  after  the  accident.  Opera- 
tion seven  hours  after  his  injury,  showing  the  stomach  wrapped  about 
by  the  omentum,  and  a  rotation  of  180  degrees,  with  the  colon  lying 
between  the  stomach  and  the  liver.  Borchardt's  case^  is  a  man,  aged 
forty-four  years,  who  was  hit  in  the  stomach  by  a  great  iron  key  and 
was  operated  on  two  days  later,  but  died  of  hemorrhage  from  the 
stomach  incision. 

The  autopsy  showed  an  aneurysm  of  the  aorta  and  a  volvulus  of  the 
stomach  of  180  degrees  on  its  horizontal  axis,  with  occlusion  of  both 
orifices,  and  the  colon  lying  underneath  the  stomach. 

In  other  cases  the  symptoms  come  on  without  previous  traumatism 
and  the  cause  for  the  volvulus  is  obscure. 

The  majority  of  writers  who  have  described  these  cases,  consider 
that  the  predisposing  cause  for  volvulus  is  a  gastroptosis,  with  the 
attendant  laxity  of  the  supporting  ligaments  of  the  stomach,  and  that 
the  exciting  cause  might  be  any  sudden  increase  of  abdominal  pressure, 
such  as  straining,  lifting,  or  coughing,  and  that,  furthermore,  the  upward 
lift  of  the  stomach  is  favored  by  distention  of  the  colon.  Gastrop- 
tosis is  so  frequent,  however,  and  volvulus  is  so  rare  that  it  seems 
difficult  to  believe  that  there  is  a  causal  relation  between  the  two.    ■ 

Symptoms. — In  many  instances  amounting  to  about  one-half  of 
the  total  luunber  of  the  cases  reported  the  symptoms  of  hour-glass 
stomach,  diaphragmatic  hernia,  or  of  gastric  adhesions  precede  those 
of  the  actual  volvulus. 

On  other  cases  the  symptoms  begin  abruptly  and  are  fairly  charac- 
teristic. Pain  is  a  constant  symptom  and  is  not  only  continuous,  but 
is  of  the  greatest  intensity  and  quite  unlike  any  pain  that  the  patient 
has  ever  before  experienced.  It  is  located  usually  in  the  epigastrium 
and  left  lower  thorax,  although  in  cases  of  volvulus  associated  with 
descent  of  the  stomach,  the  pain  may  be  located  lower  down  in  the 
abdomen.     There  is  a  })eculiar  form  of  pain  often  ob.served,  especially 

'  Mitteil.  a.  d.  Grenzj^eb.  d.  Med.  u.  Chir.,  IJand  xx,  Heft  4,  S.  70S. 
2  Arch.  f.  klin.  Chir.,  Band  Ixxiv,  Heft  2. 


SYMPTOMS  OF  VOLVULUS  423 

in  volvulus,  associated  with  diaphragmatic  hernia,  which  was  described 
by  Faure  and  by  him  designated  the  "douleur  thoracique."  This 
consists  in  a  pressure  feeling  over  the  heart  as  if  the  thoracic  box  was 
squeezed  together  with  such  force  that  it  was  about  to  break,  and  is 
in  fact  a  pressure  symptom  induced  by  a  distended  and  high-lying 
stomach.  Faure  considered  that  local  peritonitis  in  this  neighborhood 
of  the  stomach  had  a  great  deal  to  do  with  this  form  of  thoracic  pain. 

Vomiting  usually  marks  the  onset  in  the  stage  of  partial  volvulus. 
As  long  as  the  cardia  remains  patent  vomiting  is  possible,  food  being 
usually  rejected  soon  after  its  ingestion.  During  this  stage  the  stomach- 
tube  can  be  readily  passed  its  entire  length  and  the  stomach  can  be 
successfully  washed. 

There  are  undoubtedly  cases  characterized  by  pain  and  vomiting 
and  slight  shock  which  are  due  to  partial  incomplete  volvulus  and  which 
subside  either  spontaneously  or  after  the  emptying  of  the  stomach  by 
vomiting  or  lavage.  It  is  often  impossible  to  differentiate  this  condi- 
tion from  the  temporary  enlargement  of  the  stomach  in  a  diaphragmatic 
hernia  with  spontaneous  reduction. 

In  the  great  majority  of  instances,  however,  reduction  does  not  take 
place,  but  the  volvulus  becomes  complete,  with  occlusion  now  of  both 
orifices.  When  it  occurs,  vomiting  and  the  passage  of  a  tube  into  the 
stomach  become  impossible.  Retching  with  severe  effort,  but  without 
result  becomes  more  and  more  frequent,  thirst  becomes  more  and  more 
agonizing,  and  any  liquids  taken  are  immediately  rejected  without  any 
admixture  of  gastric  contents. 

When  this  clinical  picture  is  present,  with  the  characteristic  physical 
signs  and  the  impossibility  of  passing  a  stomach-tube  through  the 
cardial  orifice,  the  diagnosis  is  one  of  no  great  difficulty.  These  symp- 
toms may  last  from  a  few  hours  to  as  many  as  fourteen  days  before 
passing  into  collapse. 

Payer's  case  of  a  man  who  after  a  hearty  dinner  fell  from  a  ladder, 
landing  with  a  shock  on  his  feet,  and  who  immediately  suffered  from 
pain  and  vomiting,  was  admitted  to  the  hospital  one  hour  later.  Opera- 
tion was  unsuccessfully  performed  seven  hours  after  the  injury. 

Collishon's  case  previously  alluded  to  did  not  enter  the  hospital 
until  the  fourteenth  day. 

Collapse  is  usually  profound  and  is  usually  attended  by  some  insti- 
gation of  the  pain  and  efforts  of  vomiting. 

Death  results  from  collapse,  usually  between  the  second  to  fourth 
day  of  the  disease;  more  rarely  between  the  seventh  and  fifteenth  day. 
The  fatal  issue  may  be  hastened  by  perforative  peritonitis,  septic 
peritonitis  without  actual  perforation,  intestinal  hemorrhage  or  from 
other  lesions  of  severe  traumatism. 


424  VOLVULUS 

Diagnosis.  Physical  Examination. — The  most  constant  physical  sign 
of  volvulus  is  a  spreading  tympanitic  distention  of  the  area  occupied 
by  the  stomach.  In  the  majority  of  instances  this  distention  appears 
in  the  left  hypochondrium  and  slowly  extends,  so  as  to  occupy  more 
or  less  of  the  entire  abdomen,  the  remaining  portions  of  which  are 
ordinarily  soft  and  insensitive.  It  is  usually  possible  to  make  out  by 
palpation  the  balloon-like  form  of  the  distended  viscus. 

If  the  stomach  be  displaced  downward  the  tympanic  tumor  may 
lie  in  the  lower  abdominal  region,  as  in  Newmann's  case,  where  the 
stomach  was  palpable  below  the  navel,  and  in  Hermes'  case,  where  it 
was  found  in  the  middle  of  the  abdomen.  If  the  volvulus  complicates 
a  diaphragmatic  hernia  the  physical  signs  are  those  of  the  latter  con- 
dition and  will  be  described  under  that  heading. 

Localized  rigidity  of  the  abdominal  muscles  may  appear  early  in 
the  disease,  and  is  apt  to  spread  as  the  disease  progresses.  Should 
peritonitis  or  perforation  occur,  the  rigidity  becomes  more  intense  and 
generalized. 

The  heart  is  usually  displaced  in  the  form  of  volvulus  associated 
with  diaphragmatic  hernia  and  dextrocardia  is  the  rule.  If  the 
volvulus,  however,  be  below  the  diaphragm  the  heart  is  more  apt  to 
be  displaced  to  the  left,  although  dextrocardia  in  this  form  is  not 
infrequently  observed. 

Very  little  difficulty  should  be  observed  in  the  diagnosis  of  volvulus, 
if  the  symptoms  are  well  pronounced.  The  most  common  errors  in 
diagnosis  have  been  in  mistaking  volvulus  for  ruptured  ulcer  of  the 
stomach,  for  intestinal  obstruction  or  for  pneumothorax. 

In  perforation  of  gastric  ulcer,  we  have  the  sudden  onset  of  pain 
and  occurrence  of  shock,  as  in  volvulus,  but  the  abdomen  is  retracted 
and  board-like,  whereas  in  volvulus  we  have  the  physical  signs  of  a 
localized  spreading  of  tympany,  with  but  slightly  localized  rigidity. 
But  little  harm  is  done,  however,  by  mistaking  these  conditions,  as  in 
each  the  treatment  is  surgical. 

The  difi'erential  diagnosis  between  volvulus  associated  with  dia- 
phragmatic hernia  and  pneumothorax  will  be  considered  under  the 
heading  of  Diaphragmatic  Hernia. 

Volvulus  is  to  be  differentiated  from  a  high-lying  intestinal  obstruc- 
tion by  the  absence  of  intestinal  vomiting,  and  finally  by  the  absence 
of  vomiting  altogether  in  the  later  stages,  and  also  by  the  inability  to 
pass  a  stomach-tube  through  the  cardiac  orifice.  The  physical  signs 
of  the  spreading  area  of  tympany  with  resistance  in  the  left  hypochon- 
drium are  not  observed  in  the  intestinal  obstruction  cases. 

Hemorrhage  into  the  pancreas  should  be  thought  of  in  all  cases  of 
sudden  and  severe  abdominal  pain  and  shock  if  the  abdomen  is  sunken 


TREATMENT  OF   VOLVULUS  425 

and  rigid,  quite  different  from  the  localized  and  spreading  tympany 
of  volvulus. 

Acute  dilatation  of  the  stomach  or  "arteriomesenteric  ileus"  gives 
rise  to  physical  signs  more  or  less  identical  with  those  of  volvulus, 
but  the  onset  is  not  quite  as  acute,  and  the  stomach-tube  may  be  passed 
easily  into  the  stomach,  although  it  must  be  remembered  that  with 
lavage  in  cases  of  acute  dilatation  the  return  flow  may  be  difficult 
on  account  of  the  inability  of  the  stomach  to  contract  sufficiently  to 
allow  its  contents  to  be  expelled. 

Prognosis. — Partial  incomplete  volvulus  is  not  incompatible  with 
spontaneous  reduction  and  cure.  These  cases  are,  however,  rare  com- 
pared with  those  in  which  the  volvulus  is  complete.  When  volvulus 
once  becomes  well-developed,  recovery  without  surgical  intervention 
is  well-nigh  impossible. 

Treatment. — As  soon  as  the  diagnosis  is  made,  an  attempt  should 
be  made  to  pass  a  stomach-tube  and  to  wash  out  the  stomach,  hoping 
that  by  the  withdrawal  of  the  stomach  contents,  both  fluid  and  gaseous, 
the  twisted  organ  may  be  able  to  revert  to  its  normal  position. 
Failing  to  accomplish  this  result  no  time  should  be  wasted,  and  imme- 
diate operation  should  be  performed.  Payer's  case  was  operated  on 
seven  hours  after  the  injury  and  unsuccessfully.  A  number  of  patients 
have  been  operated  on  two  or  three  days  after  the  onset  of  the  symptoms, 
with  excellent  results,  but  it  must  be  remembered  that  the  longer  the 
case  goes  without  operative  intervention  the  greater  the  tendency 
toward  fatal  issue. 


CHAPTER  XVI 
GASTROPTOSIS 

The  term  "gastroptosis"  signifies  literally  a  descent  of  the  stomach, 
so  that  it  assumes  a  lower  level  than  normal  in  the  abdominal  cavity. 
Enteroptosis  and  splanchnoptosis  are  the  terms  used  indicating  a  down- 
ward displacement  of  the  abdominal  organs  generally,  the  stomach  as 
well  as  the  other  viscera.  These  terms,  however,  are  usually  exchange- 
able, as  gastroptosis  rarely  occurs  alone,  but  is  usually  associated  with 
general  visceral  descent — while  in  the  visceral  ptoses  in  general  the 
stomach  assumes  its  share  in  the  process. 

The  terms  "gastroptosis"  and  "splanchnoptosis"  though  not  as 
etymologically  correct  as  "  gastroptosia"  and  "  splanchnoptosia"  are 
nevertheless  sanctioned  by  long  usage,  and  are  therefore  used  by  the 
writer. 

Frequency  and  Occurrence. — The  disease  is  exceedingly  common. 
The  writer  finds  that  in  private  practice  one  patient  in  every  six  who 
applies  for  relief  from  gastro-intestinal  symptoms,  presents  evidence 
of  this  complaint,  although  not  always  to  its  full  degree  of  development. 
German  writers  state  that  it  is  more  common  in  hospital  than  in  private 
practice.  Eisner  writes  from  Berlin  that  the  disease  is  far  more  fre- 
quently seen  in  the  working  classes  than  in  those  well-to-do,  and  attrib- 
utes this  frequency  to  insufficient  nourishment  and  hard  physical  work. 
The  writer's  experience  in  New  York  is  quite  the  reverse  of  this.  Gas- 
troptosis is  of  every-day  occurrence  in  private  practice,  but  is  far  less 
commonly  seen  in  hospitals,  so  much  so  that  in  his  clinics  it  has  often 
been  difficult  to  find  a  case  for  demonstration. 

The  symi)t()ms  may  appear  at  any  age  after  puberty,  but  usually 
bec(mie  noticeable  during  the  early  portion  of  the  storm  and  stress 
period  of  life.  The  manifestations  of  the  disorder  may  then  be  con- 
tinued throughout  life  and  into  the  period  of  old  age.  Their  first  ap- 
pearance is  rarely  deferred  until  after  the  fiftieth  year.  Women  are 
more  frequent  sufferers  than  men  in  the  proportion  of  7  to  1.  This 
predisposition  to  ptosis  in  women  is  often  ascribed  to  the  natural 
lack  of  muscular  development  of  the  abdominal  wall,  too  frequent 
child-bearing  or  tight-lacing.  The  explanation  that  seems  most 
plausible  to  the  writer  is  that  the  more  sensitive  nervous  organism  of 
women   and  their  greater  predisposition  to  congenital  and   acquired 


ETIOLOGY  OF  GASTROPTOSIS  427 

neurasthenic  conditions  render  them  more  liabh-  to  the  complaint. 
The  enteroptotic  habitus  is  said  to  occur  in  ai)out  2")  jxt  cent,  of 
women,  a  far  (jreater  ])rop()rtion  than  that  o}>served  in  men. 

Etiology. — Two  distinct  causes  for  visceral  ptosis  are  described — a 
congenital  form,  due  to  inherent  physical  weakness,  and  an  acquired 
form,  due  to  relaxation  of  the  muscular  wall  of  the  abdomen,  or  to  the 
mechanical  displacement  of  the  stomach  downward  by  tight-lacing. 

Acquired  Form. — Glenard,  to  whom  we  owe  our  first  observations  of 
the  disease,  considered  that  the  starting-point  of  the  condition  was 
the  weakening  of  the  hepaticocolic  ligament,  allowing  a  falling  of  the 
hepatic  flexure  of  the  colon,  followed  by  a  relaxation  of  the  other 
ligaments  and  mesenteries  and  a  dropping  downward  of  the  viscera 
dependent  upon  them  for  support.  He  attributed  this  relaxation  to  a 
constitutional  defect  peculiar  to  certain  individuals  by  which  the 
strength  of  the  supporting  power  of  the  ligaments  and  mesenteric 
tissues  are  insufficient  to  support  their  normal  weight. 

Landau  considered  that  the  primary  cause  lay  in  an  acquired  weakness 
of  the  abdominal  wall,  giving  as  an  example  the  ptosis  commonly  ob- 
served after  childbirth.  To  the  visceral  displacement  resulting  from 
extreme  relaxation  of  the  abdominal  muscles  the  name  of  "Landau's 
F^hteroptosis"  has  been  applied. 

Meinert  considered  gastroptosis  to  be  a  frequent  accompaniment  of 
chlorosis  in  young  girls,  but  ]\Ieinert's  deductions  are  probably  inac- 
curate, as  he  diagnosticated  the  condition  whenever  he  located  the  lesser 
curvature  of  the  stomach  below  the  umbilicus  by  forcible  distention 
of  the  organ.  The  lower  border  of  any  atonic  stomach  that  is  arti- 
ficially overdistended  may  lie  too  low  in  the  abdominal  cavity,  and  it 
is  most  probable  that  many  of  Meinert's  cases  were  those  of  atony 
rather  than  of  gastroptosis. 

Keith  who  bases  his  theories  upon  anatomical  rather  than  upon  clinical 
studies,  believes  that  enteroptosis  is  the  result  of  vitiated  methods 
of  respiration.  According  to  this  WTiter,  the  organs  within  the  thoracic 
and  abdominal  cavities  are  poised  between  the  muscles  of  inspiration 
and  expiration  and  swing  with  each  respiratory  tide.  Li  the  majority 
of  people  this  respiratory  ebb  and  flow  are  so  finely  adjusted  that  the 
changes  in  the  location  of  the  viscera  do  not  occur.  In  other  cases, 
the  balance  between  inspiration  and  expiration  may  be  upset  and  the 
condition  of  enteroptosis  produced.  Keith's  conclusions  are  thus 
epitomized  by  Brown: 

"L  The  contraction  of  the  diaphragm  is  a  factor  which  produces 
a  displacement  of  the  viscera  in  splanchnoptosis  or  Glenard 's  disease, 
and  further,  that  of  the  various  parts  of  the  muscles  the  crura  are  the 
most  important  agents  in  producing  this  result. 


428  GASTROPTOSIS 

"2.  Before  this  displacement  can  be  produced,  either  what  he 
terms  the  thoracic  supports  of  the  diaphragm  must  have  yielded 
or  the  antagonistic  abdominal  muscles  must  have  been  hampered  and 
weakened  in  their  action,  as  in  the  example  of  tight  corsets. 

"3.  The  bands  which  fix  the  viscera  to  the  wall  of  the  abdomen  are 
of  quite  subsidiary  importance.  Displacement  of  the  liver  and  stomach 
arises  chiefly  from  two  causes:  relaxation  or  paresis  of  the  abdominal 
muscles  which  maintain  the  visceral  shelves,  or  more  frequently  con- 
striction of  the  body  cavity  by  clothing  or  disease,  so  that  the  normal 
respiratory  swing  forward  cannot  take  place." 

Keith's  paper  is  so  full  of  interesting  details  that  even  this  well- 
worded  epitome  fails  to  give  a  clear  idea  of  the  many  important 
observations  made  by  him  in  his  anatomical  studies  of  this  disease, 
and,  therefore,  the  reader  is  referred  to  the  original  article  in  the 
London  Lancet,  March  7  and  14,  1903. 

In  recent  times  Rosengart  by  a  study  of  fetal  development  is  led  to 
believe  that  gastroptosis  is  due  to  a  lack  of  postnatal  development  or  to 
a  reversion  toward  the  embryonic  type.  In  the  fetus  the  position  of 
the  stomach  is  vertical,  and  the  liver  rests  upon  the  superior  surface 
of  the  kidney.  After  birth  there  is  ascent  of  the  various  viscera  due  to 
the  rotation  of  the  liver  upward,  after  the  beginning  of  the  respiratory 
act,  so  that  this  organ  rises  to  the  dome  of  the  diaphragm  and  relatively 
undergoes  a  diminution  in  size,  allowing  an  upward  shift  of  the  neigh- 
boring organs.  He  believes  that  a  downward  displacement  of  the  liver 
or  a  lack  of  its  ascent  either  from  intrathoracic  causes,  which  press 
downward  upon  the  diaphragm,  or  from  external  pressure  over  the 
lower  costal  arch,  or  from  a  weakening  of  the  abdominal  muscles,  is 
the  chief  cause  for  similar  displacements  of  the  neighboring  organs 
and  their  reversion  to  the  congenital  position. 

Tight-lacing  has  always  been  held  responsible  for  gastroptosis. 
Rovsing^  divides  gastroptosis  into  the  virginal  and  the  maternal  types. 
The  first  variety  occurs  in  young  girls  and  is  distinctly  attributable 
to  their  misuse  of  corsets  and  laces,  while  in  the  maternal  type  the  change 
in  the  intra-abdominal  pressure  due  to  pregnancy  and  child-bearing 
is  responsible  for  the  disorder.  To  this  view  of  Rovsing  the  writer 
cannot  agree,  as  it  does  not  seem  that  tight-lacing  has  been  a  factor  in 
inducing  the  ailment  in  more  than  a  very  few  of  his  patients.  Rovsing 
does  not  indicate  the  causes  for  the  ailment  in  men  who  have  neither 
worn  tight  corsets  nor  borne  children.  Tight-lacing  is  if  anything  more 
common  in  those  without  gastroptosis  than  in  those  who  are  the  subjects 
of  this  disorder,  as  the  former  patients  are  usually  more  cor])ulent 

'  Jour.  Amer.  Med.  Assoc,  August  3,  1911. 


ETIOLOGY  OF  GASTROPTOSIS  429 

and  therefore  more  apt  to  laee  themselves  tightly.  The  older  form  of 
corset  which  causes  constriction  about  the  waist  line  as  would  a  tight 
narrow  belt  is  undoubtedly  injurious,  hampering  diaphragmatic  breath- 
ing and  tending  to  displace  downward  the  organs  in  the  thoracic  ab- 
domen ;  but  the  modern  straight  front  corset  is  free  from  these  objections 
and  is  beneficial  rather  than  injurious.  In  those,  however,  whose 
physical  conformation  is  that  described  by  Stiller,  with  long  thorax 
and  low-lying  costal  arch,  clothing  that  is  too  tightly  belted  about 
the  waist  may  press  upon  the  lower  costal  arch  instead  of  on  a  line 
below  the  ribs,  as  in  normal  people,  and  may  thus  displace  the  entire 
costal  arch  so  as  to  diminish  the  capacity  of  the  thoracic  abdomen 
and  cause  a  downward  displacement  of  the  organs  normally  situated 
within  its  confines. 

Congenital  Form. — The  most  important  contribution  to  the  study 
of  gastroptosis  has  come  from  Stiller,  who  considers  that  visceral 
ptoses  accompany  a  peculiar  form  of  physical  development  which  he 
describes  by  the  term  Habitus  Enteroptoticus  or  Habitus  Paralyticus. 
The  thorax  is  long  and  narrow,  the  epigastric  angle  is  abnormally  acute 
and  the  costal  arches  run  downward  and  outward  in  a  long  more  or 
less  vertical  sweep  that  gives  a  narrow  elongated  shape  to  the  thoracic 
abdomen,  greatly  diminishing  its  capacity. 

Owing  to  the  abnormal  development  of  the  thoracic  abdomen  and 
to  its  diminished  capacity,  the  organs  contained  within  its  confines 
have  no  space  to  lie  transversely,  but  are  forced  to  assume  a  more 
vertical  position  and  to  be  pushed  downward  to  obtain  sufficient  room 
for  growth  and  activity,  so  that  ptosis  is  obviously  bound  to  occur. 

With  such  a  conformation,  improperly  fitted  corsets  and  tight  belt 
lines  constrict  the  lower  arches  of  the  ribs,  as  they  are  lower  than  in 
other  individuals  and  tend  to  add  to  the  displacement. 

The  writer  is  absolutely  in  accord  with  Stiller's  views.  All  mankind 
may  be  divided  into  two  classes :  those  with  and  those  without  the  entero- 
ptotic  habit.  Those  without  the  enteroptotic  habit,  who  are  possessed 
of  a  broad  thorax  and  wide  costal  angle,  are  not  apt  to  be  neurasthenic. 
If  they  suffer  from  gastro-intestinal  distress  it  is  apt  to  be  the  result 
of  organic  disease.  Those,  on  the  other  hand,  who  show  the  stigmas  of 
the  enteroptotic  habit,  whose  abdomen  and  thorax  are  long  and  narrow 
and  whose  costal  arch  is  sharp,  are  constitutionally  and  temperamentally 
neurasthenic  and  are  subject  to  a  great  variety  of  functional  disorders. 
When  such  a  patient  sufters  from  gastro-intestinal  distress,  while  there 
may  be  an  organic  cause  present,  it  is  fair  to  assume  that  a  large  pro- 
portion of  the  symptoms  are  neurasthenic  or  functional  in  character. 

In  all  such  patients  as  Stiller  describes,  weakening  of  the  abdominal 
wall  from  anv  cause  whatever  tends  further  to  increase  the  natural 


430 


GASTROPTOSIS 


tendency  to  downward  displacement  and  may  therefore  be  regarded 
as  a  contributory  cause  for  the  fuller  development  of  visceral  ptosis. 
There  are,  however,  a  small  number  of  patients  in  whom  the  bodily 
conformation  is  normal,  the  thorax  is  broad,  the  costal  angle  wide,  and 

in  whom  the  downward  displace- 
FiG.  S3  ment  of  the  stomach  is  effected  by 

])urely  mechanical  causes,  such  as 
weakening  of  the  abdominal  wall, 
often  with  or  without  diastasis  of 
the  recti,  either  the  result  of  fre- 
quent pregnancies  or  due  to  the 
remo^'al  of  large  abdominal  tumors, 
or  the  repeated  withdrawal  of  asci- 
tic fluid.  The  stomach  may  be, 
moreover,  displaced  by  the  weight 
of  attached  tumors,  or  dragged  by 
adhesions  into  a  faulty  position. 
In  the  latter  instances,  the  dis- 
l)lacement  of  the  stomach  is  not 
accompanied  by  other  visceral 
l)toses,  and  does  not  come  within 
the  description  of  the  disease  as 
gi^'en  in  the  present  article. 

Enteroptosis  in  Children. — Often 
in  children  are  observed  signs  of 
muscular  insufficiency  and  frailness 
of  frame  representing  the  primary 
characteristics  of  the  enteroptotic 
habit  of  the  adult.  Changes  in  the 
shape  of  the  thorax  and  angle  of 
the  ribs  are  seldom  demonstrable 
until  the  twelfth  year,  which  is  the 
period  marking  the  transition  from 
the  infantile  to  the  adult  form  of 
bodily  development.  Until  this  age 
is  reached  there  is  very  seldom  any 
actual  descent  of  the  stomach  or  other  viscera.  The  stomach  lies 
well  above  the  umbilicus  mitil  after  the  twelfth  and  fourteenth  year, 
although  the  lower  pole  may  be  distinctly  hooked. 

Position  and  Shape  of  the  Stomach  in  Gastroptosis. — From  the  cardia 
to  the  outer  extremit\'  of  the  first  inch  of  duodeinun  the  stomach  is 


(A.  H.  ;iiul  Iv  H.)  Two  children,  aged 
elevon  years.  Contrast  contour  of  form,  amount 
of  fat,  muscular  development,  bony  frame,  and 
size  of  chest.' 


'  Smith,  .Jour.  Anier.  Med.  A.s.soc.,  1012,  Iviii,  3!tl. 


SYMPTOMS  OF  G  AST  HO  PTOSIS 


431 


surrounded  by  peritoneum  and  is  freely  movable,  although  the  radius 
of  motion  of  the  pylorus  is  small  compared  to  the  })ody  of  the  stomach. 
Being  swung  between  these  two  fixed  points  as  the  organ  sags  it  assumes 
a  vertical  position  terminating  in  a  well-marked  upward  hook  just 
before  the  pylorus  is  reached — at  about  the  line  of  the  incisura  angularis, 
— so  that  a  "looped"  or  "fish-hook"  form  is  produced.  If  the  pyloric 
end  be  fairly  well  maintained  in  place,  the  bend  is  more  pronounced 
and  the  ascending  arm  is  more  vertical,  so  that  the  stomach  assumes 
the  "water-trap"  or  "drain-trap"  form.  When  the  duodenal  attach- 
ments are  relaxed,  the  whole  pyloric  end  sinks  until  all  but  about  the 
pyloric  region  itself  lies  nearly  vertically  up  and  down. 


Fia.  84 


Ptosis.     A,  in  the  vertical  position;  B,  in  the  horizontal  position.     (Hertz. J 

When  food  is  put  into  the  stomach  the  lower  limit  of  the  organ 
sags  more  and  more  deeply  into  the  abdomen,  and  the  body  of  the 
stomach  lies  more  nearly  vertical.  The  tubular  form  of  the  body  well 
constricted  by  normal  tonus  upon  its  contents  is  rarely  seen,  as  the 
food  column  is  slight  in  diameter  or  even  entirely  absent,  so  that  the 
outline  of  the  stomach  shows  a  large  pear-shaped  or  bulbous  air-bubble 
at  its  upper  end  connected  by  a  collapsed  and  empty  body  of  the  organ, 
with  a  lower  food  chamber  which  is  sagged  downward  by  mechanical 
weight.  In  advanced  cases  of  hypotonus  there  may  be  a  close  resem- 
blance to  an  hour-glass  stomach.  These  changes  in  outline  are  clearly 
evident  when  the  patient  stands,  but  disappear  when  he  lies  down. 
In  recumbency  the  greater  curvature  may  be  well  above  the  navel, 
so  that  in  this  posiiion  the  a;-ray  may  not  afford  the  least  proof  of  any 
degree  of  ptosis. 

Symptoms. — Gastroptosis  often  exists  without  giving  rise  to  any 
local  symptoms,  and  may  run  for  years  an  entirely  latent  course.  A 
displaced  stomach  will  do  its  work  without  sj^mptoms  of  indigestion, 
unless  it  becomes  atonic,  to  which  condition  it  is  by  nature  predisposed. 
Whenever  symptoms  appear  they  are  regularly  due  more  to  the  atony 


432  GASTROPTOSIS 

than  to  the  gastroptosis  itself.    The  whole  symptomatology  and  treat- 
ment of  gastroptosis  is  that  of  atony.    We  describe  therefore: 

1.  Gastroptosis  without  atony. 

2.  Gastroptosis  wuth  atony. 

Gastroptosis  without  Atony. — In  this  stage  there  are  few  if  any  gastric 
symptoms,  certainly  none  that  are  characteristic  or  prominent.  Neur- 
asthenic symptoms  are,  however,  more  or  less  pronounced,  and  the 
patient  is  apt  to  be  of  unstable  nervous  temperament,  easily  affected 
by  environment,  and  without  mental  or  physical  endurance.  Strains 
that  should  not  be  considered  excessive  are  followed  by  an  abnormal 
physical  and  mental  reaction. 

Nutrition  is  regularly  below  par,  and  it  is  often  a  matter  of  serious 
concern.  These  are  the  patients  who  are  constantly  taking  tonics, 
and  who  are  forced  to  leave  home  every  little  while  to  "rest  up"  and 
regain  what  they  have  lost  by  the  friction  of  daily  life.  The  bowels, 
as  a  rule,  are  constipated. 

Physical  examination  almost  invariably  shows  the  enteroptotic 
habitus — the  long  abdomen  and  thorax,  narrow  costal  angle,  together 
with  evidences  of  visceral  ptoses.  The  description  of  the  physical  signs 
are  given  in  full  detail  in  a  later  section. 

The  early  recognition  of  these  cases  is  of  extreme  importance,  because 
it  must  be  acknowledged  at  the  start  that  such  a  patient  is  unable  to 
stand  as  well  as  others  the  storm  and  stress  of  life,  but  that  they  are 
always  more  or  less  delicate  and  will  have  to  conserve  as  far  as  possible 
their  nervous  and  physical  energies  all  through  life.  It  is,  therefore, 
important  to  inaugurate  a  prophylactic  treatment  that  will  minimize 
their  liability  to  succumb  by  the  way. 

Gastroptosis  with  Atony. — Gastroptosis  with  atony  runs  a  different 
clinical  course  in  the  congenital  and  in  the  acquired  cases.  In  the 
former  group  the  gastro-intestinal  symptoms  are  combined  with  those 
of  the  underlying  neurasthenic  habit,  so  as  to  form  a  varied  clinical 
picture,  while  in  the  acquired  type  of  the  disorder  the  symptoms  are 
those  of  the  gastric  ailment  itself  without  the  same  predominance 
of  i)er\()us  phenomena.  The  following  description  of  the  symptoms 
will  apply  more  definitely  to  the  former  group;  the  difference  in  the 
clinical  course  of  the  two  forms  will  be  alluded  to  later  in  the  discussion. 

If  patients  with  gastroptosis  live  within  their  physical  and  nervous 
limitations  they  are  not  apt  to  suffer,  but  if  these  limitations  are  trans- 
gressed, symptoms  of  indigestion  and  of  neurasthenia  regularly  appear. 
At  first  the  symptoms  appear  only  from  time  to  time,  induced  by  some 
unwonted  physical  or  mental  strain  and  are  but  transient,  disappearing 
when  the  patient  regains  the  vitality  that  has  been  lost.  Relapses 
occur,  however,  so  that  the  symptoms  tend  to  become  more  or  less 


SYMPTOMS  or  GASTROPTOSIS  433 

continuous,  and  to  persist  until  radical  means  are  taken  to  restore 
nervous  and  physical  tone  and  to  relieve  the  atonic  condition  of 
the  stomach  wall  itself. 

In  90  per  cent,  of  the  writer's  cases  the  symptoms  began  after  a 
definite  and  existing  cause.  Prolonged  nervous  strain,  sudden  mental 
shocks,  grief,  depression  of  spirits,  disappointments  in  love,  are  the 
most  frequent  causes  adduced.  The  history  of  physical  strain  is  not 
infrequently  elicited;  any  severe  or  exhausting  illness,  such  as  typhoid 
fever,  or  la  grippe  may  be  followed  by  gastric  symptoms,  or  the  strain 
of  hard  travel,  nursing  sick  relatives,  or  long  business  hours  may  so 
devitalize  an  individual  with  an  enteroptotic  inheritance  as  to  cause 
more  or  less  complete  invalidism. 

In  many  patients  the  history  of  a  definite  exciting  cause  may  not 
be  obtained,  but  the  clinical  history  brings  out  clearly  enough  that  the 
patient  is  quite  unable  to  endure  the  wear  and  tear  of  the  ordinary 
demands  of  life.  The  history  of  almost  every  patient  with  gastroptosis 
may  be  divided  into  three  stages. 

'  1.  The  stage  without  atony  in  which  the  symptoms  are  those  of 
subnutrition,  neurasthenia,  and  lack  of  vitality. 

2.  A  stage  of  temporary  and  recurring  atony  following  ph}'sical  or 
nervous  strain,  and  accompanied  by  intermitting  symptoms. 

3.  The  stage  of  permanent  atony  in  which  the  symptoms  are 
continuous. 

An  appreciation  of  these  three  successive  stages  of  the  disease  is 
essential  to  a  rational  and  intelligent  treatment.  These  stages  are 
well  illustrated  in  the  following  history,  which  is  quite  typical  of  the 
course  of  the  ailment: 

L.  R.,  a  lady,  aged  twenty-seven  years,  was  a  delicate  under- 
nourished child,  and  though  free  from  serious  illness  was  always  taking 
tonics.  She  never  could  lead  the  life  that  her  companions  did  without 
having  to  rest  up  for  long  periods  at  a  time.  When  fifteen  she  noticed 
that  from  time  to  time,  following  physical  or  nervous  fatigue,  she 
suffered  from  heart-burn,  gas  in  the  stomach,  and  distress  after  meals. 
These  symptoms  disappeared  after  she  rested.  When  eighteen  she 
entered  upon  an  active  social  life  and  did  a  great  deal  under  high 
tension.  Symptoms  now  became  continuous  and  severe,  she  lost 
weight  and  became  a  nervous  wreck.  The  more  she  dieted  the  worse 
she  became. 

The  symptoms  of  gastroptosis  may  be  divided  into  four  groups: 

1.  The  symptoms  of  atony. 

2.  Subnutrition. 

3.  Neurasthenia. 

4.  Symptoms  due  to  associated  displacements. 
28 


434  ,  GASTROPTOSIS 

1.  Symptoms  of  Atony. — The  symptoms  due  to  atony  in  gastroptosis 
do  not  differ  in  the  least  from  those  due  to  atony  however  induced, 
except  that  flatulence  is  a  more  constant  and  prominent  symptom  and 
is  usually  most  annoying  two  or  three  hours  after  eating,  although  it 
may  be  most  severe  during  the  night  or  awaking  the  patient  during 
the  early  morning  hours.  Most  of  the  gas  is  raised,  but  a  considerable 
quantity  remains  and  may  occasion  constant  distress.  The  flatulence, 
as  in  atony,  is  influenced  by  the  bulk  and  weight  of  the  food  rather 
than  by  its  quality,  and  the  patients  are  very  apt  to  attribute  their 
discomfort  to  what  they  eat  and  reduce  their  diet  to  a  starvation  point 
without  any  relief  from  their  distress.  Intestinal  distention  occurs 
later  after  eating  than  does  gastric  flatulence  and  is  more  continuous. 
Heaviness,  a  feeling  of  fulness  and  weight  in  the  stomach,  especially 
after  eating,  are  prominent  symptoms  in  the  majority  of  instances. 

Actual  pain  is  not  a  common  symptom  but  it  occurs  more  frequently 
than  in  the  cases  of  simple  atony.  The  pain  may  be  due  to  a  variety 
of  causes.  Painful  distention  of  the  stomach  may  occur  from  accumula- 
tion of  gas,  and  is  relieved  when  gas  is  raised.  It  is  probable  that  in 
many  of  these  instances  the  cause  is  to  be  found  either  in  mesenteric 
constriction  of  the  duodenum  by  downward  traction  of  the  root  of  the 
mesentery  and  superior  mesenteric  artery,  as  the  result  of  prolapse 
of  the  intestine,  or  downward  displacement  of  the  small  intestine  may 
drag  upon  the  duodenum  at  certain  fixed  points,  either  at  the  angle 
of  the  first  and  second  portion  of  the  duodenum  or  at  the  duodeno- 
jejunal junction,  and  produce  a  certain  degree  of  obstruction. 

Robinson,^  indeed,  believes  duodenojejunal  obstruction  is  frequently 
the  cause  of  death  in  gastroptosis  cases  over  forty  years,  as  he  has  found 
15  or  20  cases  of  distinct  and  extensive  gastro-intestinal  dilatation  on 
the  right  side  of  the  superior  mesenteric  bloodvessels.  This  the  writer 
thinks  is  an  extreme  statement  not  corroborated  by  clinical  observa- 
tion. These  factors  are  not  sufficient  in  gastroptosis  to  produce  food 
stasis,  as  is  proved  by  the  emptiness  of  the  fasting  stomach  on  examina- 
tion, although  they  are  undoubtedly  capable  of  producing  considerable 
distress  and  distention. 

Pain  may  be  referred  to  the  left  costal  arch  and  is  apparently  due  to 
the  dragging  of  the  gastrosplenic  ligament.  The  condition  is  made 
worse  by  exercise,  especially  after  eating,  and  is  relieved  by  rest  or  by 
firm  strapping  of  the  abdomen,  as  by  the  application  of  a  Rose's  belt. 
Dull,  diffused  epigaetric  pain  may  occur  after  prolonged  exercise  and 
appears  to  be  due  to  traction  on  the  gastrohepatic  ligament.  It,  too, 
is  relieved  by  rest  and   strapping.    Intermittent  attacks  of  pain  in 

'  Cincinnati  Clinic,  577,  December  8,  1900. 


SYMPTOMS  OF  GASTROPTOSIS  4:^5 

the  stomach  may  be  due  to  pylorospasm  resulting  from  a  chronic 
appendicitis,  a  not  uncommon  complication. 

Pain  in  the  back,  intensified  by  exercise,  is  often  of  orthostatic 
origin  and  is  due  to  faulty  means  of  standing  or  walking,  causing 
undue  strain  on  certain  ligaments. 

Nausea  is  more  frequent  with  gastroptosis  than  with  simple  atony, 
although  in  both  conditions  the  characteristics  of  the  symptom  are 
the  same,  coming  and  going  through  the  day  without  fixed  relationship 
to  the  meals,  or  to  the  character  of  the  food  that  is  eaten.  A^omiting 
is  an  uncommon  symptom.  When  it  does  occur  it  presents  nothing 
that  is  characteristic  of  the  ailment. 

Rovsing  claims  that  hematemesis  with  gastroptosis  is  not  infre- 
quent, but  with  this  the  writer  cannot  agree.  If  hematemesis  occurs 
the  bleeding  is  due  to  some  intercurrent  affection  rather  than  to  the 
gastroptosis  itself. 

Auto-intoxication  symptoms  are  present  as  in  simple  atony,  and  are 
usually  more  severe  and  continuous. 

Headache,  either  periodical  and  hemicranial  in  type,  accompanied 
by  nausea  and  vomiting,  or  dull  and  occipital,  is  commonly  observed. 

2.  Symptoms  of  Subnutrition. — As  a  rule  the  patients  are  thin  and 
poorly  nourished  from  infancy,  and  their  tendency  toward  subnutrition 
is  maintained  throughout  their  life.  When  atonic  symptoms  appear 
loss  in  weight  becomes  more  noticeable.  At  first  the  patients  lose  only 
after  they  have  become  tired  and  nervous  and  after  a  period  of  rest 
regain  all  they  have  lost,  but  when  the  stage  of  permanent  atony  is 
reached  the  power  of  recuperation  is  lost.  When  through  their  own 
volition  or  by  injudicious  medical  advice  the  diet  is  unduly  restricted, 
loss  of  weight  often  becomes  extreme,  so  that  the  patients  may  not 
weigh  more  than  70  to  80  pounds,  although  for  their  height  and  bony 
framework  a  weight  of  125  to  140  pounds  would  be  normal.  Every 
patient  with  gastroptosis  should  be  regularly  and  systematically  weighed 
and  records  kept.  No  treatment  will  be  found  beneficial  that  is  not 
attended  by  a  progressive  gain,  and  the  symptoms  are  not  apt  to  im- 
prove until  the  patient  is  10  to  12  pounds  heavier. 

3.  Symptoms  of  Neurasthenia. — Symptoms  of  neurasthenia  are  regularly 
present.  The  variety  of  the  nervous  complaints  is  almost  unlimited 
and  their  severity  runs  a  course  parallel  with  that  of  the  general  condi- 
tions. The  danger  is  that  we  may  be  diverted  by  these  nervous  manifes- 
tations of  disease  and  make  the  foolish  diagnosis  of  nervous  indigestion 
without  thoroughly  examining  the  patient  and  recognizing  that  these 
expressions  of  neurasthenia  constitute  but  part  of  a  broad  symptom- 
complex  which  embraces  also  the  signs  and  symptoms  of  gastro- 
intestinal aton^•  and  of  inherent  lack  of  assimilation. 


436  GASTROPTOSIS 

In  an  article  1)\'  Birtch  and  Tnman^  the  relation  between  the  nervons 
symptoms  and  the  blood  pressure  is  admirably  considered,  and  con- 
clusions are  as  follows: 

In  patients  with  marked  abdominal  relaxation  the  systolic  blood 
pressure  falls  from  10  to  25  mm.  H^.  on  standing  after  lying.  There 
occurs  at  the  same  time  an  increase  in  the  pulse  rate,  undoubtedly 
intended  to  compensate  for  the  fall  in  systolic  pressure,  but  inadequate 
to  oA'ercome  entirely  the  effect  of  gravity.  If  the  diastolic  blood  i)ressure 
be  well  maintained  the  effect  of  gravity  is  compensated  and  circulatory 
disturbances  are  absent. 

The  diai)hragm  is  an  important  adjunct  to  the  circulation.  Acting 
in  opposition  to  the  abdominal  muscles  it  forms  a  respiratory  pump 
and  assists  in  lifting  the  blood  from  the  abdominal  veins  to  the  right 
heart.  In  relaxation  of  the  abdominal  muscles  there  is  a  decrease  in 
the  intra-abdominal  pressure  and  a  decrease  in  the  aspirating  power 
of  the  diaphragm  which  tend  to  diminish  the  volume  of  blood  in  the 
arteries  and  to  permit  the  stagnation  of  blood  in  the  visceral  veins. 
It  is  not  unnatural  to  suppose  that  there  must  necessarily  be  some 
effect  observed  on  the  cerebral  circulation  to  which  some  of  the  symp- 
toms can  be  ascribed.  In  this  connection  Haven  Emerson-  writes: 
"Any  marked  loss  of  abdominal  tone  is  recognized  clinically  as  a  con- 
tributing cause  of  venous  stagnation  in  the  abdominal  viscera,  and  this 
means  a  delayed  or  insufficient  return  to  the  right  heart,  a  diminished 
output  and  a  fall  in  the  arterial  pressure,  or  a  pressure  maintained  only 
at  the  expense  of  greater  cardiac  action." 

Dizziness  and  insomnia  in  gastroptosis  are  probably  the  result  of 
changes  in  blood  })ressure.  According  to  Birtch  and  Inman,  when 
dizziness  is  present  the  blood  pressure  shows  both  systolic  and  diastolic 
fall  if  the  patient  stands.  The  writer  believes  that  many  cases  of  in- 
somnia are  due  to  the  fact  that  in  the  recumbent  position  the  blood 
])ressure  is  increased  o\er  what  it  is  in  the  vertical  position,  producing 
an  accelerated  cerebral  circulation  for  a  considerable  time  after  lying 
down,  so  that  the  onset  of  sleep  is  retarded. 

The  good  effect  of  rest  in  bed  in  these  cases  may  be  due  to  the  fact 
that  in  the  horizontal  ])osition  the  piston-like  action  of  the  diaphragm 
is  not  required  for  circulation.  When  the  \ertical  ])osition  is  assumed 
the  action  of  the  diaphragm  unopposed  l)y  the  abdominal  muscles  is 
inadequate  to  do  its  work  and  maintain  blood  ])ressure  as  it  should. 
The  imi)r()vement  noticed  after  aj)i)lying  a  firm  abdominal  belt  may  be 
due  more  to  the  increase  of  abdominal  pressure  afforded,  than  to  its 
mechanical  assistance  in  holding  the  viscera  in  ])lace. 

'  .Four,  .\nier.  Med.  .\s.soc.,  January  27,  l'.tl2. 
-  .Vrchivcs  Internal  Medicine,  June  1911,  p.  754. 


SYMPTOMS  OF  GASTROPTOSIS  137 

4.  Symptoms  Due  to  Associated  Displacements. — The  colon  usually  saj^s 
in  its  transverse  i)()rtion  assuming'  an  M-sliape,  the  sj)lenic  flexure  l)eing 
held  well  in  ])lace  although  the  hej^atic  angle  is  lower  in  the  abdomen 
than  normal.  With  such  a  condition  a  certain  degree  of  colon  stasis  is 
inevitable,  and  the  absorption  from  its  retained  contents  almost 
regularly  produces  the  toxic  symptoms  that  are  characteristic  of  all 
forms  of  intestinal  stasis  and  are  classified  by  Arbuthnot  Lane  as 
follows : 

1.  The  skin  becomes  thin,  inelastic,  and  wrinkled.  There  is  a  general 
staining  most  marked  in  frictional  areas,  and  is  common  in  and  about 
the  eyelids.  The  secretions  of  the  skin  are  abundant  and  offensive, 
especially  in  the  axilla. 

2.  The  circulation  becomes  enfeebled,  the  blood  pressure  lowered. 
Should  degenerative  changes  later  develop  in  the  heart,  bloodvessels, 
or  kidneys,  the  blood  presure  may  be  very  high.  The  rate  of  the  pulse 
is  variable,  being  increased  in  frequency  by  any  exercise,  or  by  accumu- 
lations of  gas  in  the  abdomen.  A  condition  closely  resembling  asthma 
may  sometimes  result.  The  extremities  are  cold  even  in  the  hottest 
weather,  and  the  transition  from  the  warm  to  the  cold  area  is  often 
very  abrupt. 

3.  The  temperature  is  habitually  subnormal. 

4.  Muscular  strength  fails  so  that  the  patient  is  quite  unable  to  take 
his  daily  exercise. 

5.  Nervous  symptoms  are  very  marked.  The  patients  become 
stupid  and  apathetic  during  the  day  and  often  sleep  badly  at  night. 
They  awake  in  the  morning  with  a  headache  and  feel  that  they  have 
derived  no  benefit  from  their  sleep.  Headache  is  a  common  and  dis- 
tressing symptom. 

6.  Enlargement  and  tenderness  of  the  terminal  joints  of  the  hands 
and  feet  are  not  uncommon,  and  may  be  classed  as  an  affective  osteo- 
arthritis due  to  intestinal  toxins  of  unknown  nature. 

7.  Lane  speaks  of  changes  in  the  breast  which  are  always  present 
when  auto-intoxication  has  existed  for  any  length  of  time,  consisting  in 
an  induration  in  the  upper  and  outer  zone  of  the  left  breast  and  later 
in  the  same  area  on  the  right  side.  As  time  goes  on  this  induration 
spreads,  but  always  remains  in  the  upper  and  outer  segment  in  excess 
of  that  in  the  rest  of  the  breast. 

Mucous  colitis  almost  invariably  accompanies  the  displacement 
of  the  colon  and  is  characterized  by  the  passage  of  mucus  in  long, 
strings  or  in  free  masses  more  or  less  admixed  with  the  stools. 

In  the  writer's  experience  the  subjective  symptoms  of  such  a  mucous 
colitis  are  practicall}'  negligible.  Pain  does  not  seem  to  occur  unless 
there  be  a  complicating  appendicitis.     Unfortunately  the  combination 


438  GASTROPTOSIS 

of  a  mucous  colitis  and  a  chronic  inflammation  of  the  appendix  is  not 
at  all  an  unusual  one. 

A  downward  displacement  of  the  kidney  may  occur,  usually  on  the 
right  side,  occasionally  on  both.  Displacement  of  the  left  kidney  alone 
occurs  but  rarely.  Fortiniately  the  day  has  passed  when  every  palpable 
kidney  ran  the  risk  of  being  sewed  up  in  its  proper  place,  but  the  idea 
that  movable  kidneys  are  productive  of  distress  and  discomfort  to  their 
host  is  dying  hard.  It  is  but  rare  that  symptoms  of  any  moment  result 
from  nephroptosis,  no  matter  how  extreme  the  displacement  may  be. 
It  is  conceivable  that  a  large  floating  kidney  may  exert  deleterious 
pressure  on  neighboring  structures.  This,  however,  is  a  clinical  rarity. 
It  is  only  when  rotation  of  the  kidney  is  allowed  by  the  laxity  of  its 
ligaments  with  a  resulting  torsion  of  the  ureter  that  characteristic 
symptoms  appear,  characterized  by  the  symptom  complex  known  as 
Dietl's  crisis. 

The  liver  may  or  may  not  be  displaced  downward,  depending  upon 
the  strength  of  its  supporting  ligament.  Hepatoptosis  may,  how'ever, 
be  quite  extreme,  the  liver  not  only  sagging  downward  but  tilting 
forward  and  downward  on  its  transverse  axis  so  that  the  edge  may 
be  palpable  2  or  3  inches  below  the  costal  arch.  A  dragging  feeling 
on  exertion  in  the  region  of  the  organ  is  the  characteristic  symptom 
of  the  displacement. 

The  symptoms  of  gastroptosis  unassociated  with  the  enteroptotic 
habitus,  that  are  due  to  mechanical  weakening  of  the  abdominal  wall, 
as  in  Landerer's  cases,  differ  from  those  just  described,  in  the  absence 
of  a  definite  and  obvious  neurasthenic  state.  Gastric  symptoms  of 
atony,  auto-intoxication,  and  symptoms  of  intestinal  origin,  are  usually 
well-marked  and  characteristic,  but  the  patients  do  not  lose  in  weight 
as  in  the  congenital  form,  nor  are  the  nervous  symptoms  as  prominent, 
and  although  a  variety  of  psychasthenic  symptoms  may  occur,  they 
do  not  seem  to  form  so  inherent  a  part  in  the  morbid  progress  and 
are  more  readily  amenable  to  treatment. 

Physical  Signs. — Much  can  be  learned  by  the  inspection  of  the 
patient.  The  most  important  presumptive  evidence  of  the  disorder 
is  the  presence  of  the  enteroptotic  habitus.  The  epigastric  angle  is 
abnormally  sharp.  The  writer  has  made  it  a  routine  to  measure  the 
costal  angle  in  every  case,  and  finds  that  when  the  ribs  part  at  a  more 
acute  angle  than  50  degrees  to  55  degrees  the  atonic  and  neurasthenic 
defects  of  the  enteroptotic  habitus  are  almost  invariably  present,  even 
though  an  actual  descent  of  the  stomach  may  not  be  extreme.  The 
distance  between  the  ensiform  cartilage  is  greater  than  the  horizontal 
measurement  from  the  umbilicus  to  the  costal  arch. 

It  has  been  attempted   to  calculate  the  capacity  of  the  thoracic 


PHYSICAL  SIGNS  OF  GASTRO PTOSIS 


439 


abdomen  and  to  express  the  result  in  figures.  The  "  jugulo-pubic  index" 
of  Becker  and  Lenhoff  is  determined  as  follows:  The  measurement 
from  the  suprasternal  notch  to  the  upper  border  of  the  symphysis 
pubis  is  divided  by  the  circumference  of  the  waist  line  at  its  point  of 
greatest  constriction  and  the  result  is  multiplied  by  100.    If  the  figure 


Fig.  85 


Enteroptotic  habitus. 


thus  obtained  equals  or  exceeds  77,  the  individual  belongs  to  the  entero- 
ptotic group.  In  general  Becker  and  Lenhoff's  index  works  true,  but 
seems  to  the  author  to  possess  no  advantage  over  the  simpler  method 
of  determining  the  epigastric  angle. 

The  patient  is  slender  and  has  but  slight  adipose  tissue.    The  muscles 
are  underdeveloped  and   there  is  a  tendency  on  standing   toward  a 


440 


CASTROPTOSIS 


bulging  fold  of  the  lower  ])ortion  of  the  abdominal  wall.  This,  however, 
may  not  be  apparent  in  young  subjects  who  have  not  borne  children. 
The  chest  is  shallow,  the  upper  ribs  are  far  apart,  the  lower  slanting 
more  in  a  downw'ard  direction  than  can  be  observed  in  normal  cases. 
These  characteristics  become  more  and  more  apparent  during  the  growth 


Vie.   SCi 


Normal  luibitii.s 


of  the  child  to  maturity.  Relaxed  condition  of  the  abdominal  wall 
should  be  noted  and  the  degree  of  bulging  of  the  lower  abdominal  zones 
should  be  observed  both  in  the  recumbent  and  standing  positions. 

Evidences  of  downward  dis])laccmcnt  of  the  stomach  may  be  obtained 
with  reas()nal)lc  accnr;i(\'  in  a   nnnibcr  of  wa\s.     The  finding  of  the 


PHYSICAL  SIGNS  OF  GASTROPTOSIS 


441 


greater  curvature  l)el()w  the  uiiibilieiis  does  not  necessarily  ])rove  that 
gastroptosis  is  present.  Normal  stomachs  heavily  laden  with  food  may 
sag  if  the  patient  stands  so  that  the  greater  curvature  falls  below  the 
umbilicus.  On  lying  down,  however,  the  greater  curvature  rises  1  or 
2  inches  and  tends  to  lie  above  the  navel.     All  atonic  stomachs  are 


Fig.   b 


Author's  angulator  for  measurement  of  the  costal  angle. 


abnormally  distensible,  so  that  they  sag  downward  as  more  and  more 
food  is  put  into  them,  but  they  reassume  their  normal  position  when 
they  are  free  from  the  mechanical  weight  of  their  contents.  It 
would,  therefore,  be  a  sad  misconception  to  consider  all  stomachs 
gastroptotic  by  locating  the  greater  curvature  alone. 


442 


GASTROPTOSIS 


Gastroptosis  cannot  he  ruled  out  if  it  be  found  on  a  single  examina- 
tion alone  that  the  lower  curvature  in  the  recumhent  position  is  above 
the  na\'el,  as  recumbency  for  any  length  of  time  may  allow  a  stomach 
that  is  ordinarily  displaced  to  work  up  into  normal  position.  To  deter- 
mine the  size  and  position  of  the  stomach  three  methods  of  examination 
may  be  employed: 


Fig.  88 


Normal  stoiiiacli.     .1.  in  vertical  position;  B,  in  horizontal  position.     (Hertz.) 


1.  The  lowest  point  at  which  succussion  sounds  are  elicited  by 
slight  palpation  may  be  considered  the  lowest  boundary  of  the  organ. 
If  the  succussion  sounds  are  not  readily  audible  the  patient  may  be 
allowed  to  drink  a  half-glass  of  water.  The  determination  of  the  lower 
border  of  the  stomach  by  such  a  method  of  examination  is  somewhat 
crude  and  often  totally  inaccurate. 

2.  Artificial  dilatation  is  sufficiently  accurate  for  all  clinical  pur- 
poses, provided  that  we  bear  in  mind  that  all  atonic  stomachs,  whether 
displaced  downward  or  not,  are  abnormally  distensible  and  that  con- 
sequently overdistention  will  locate  the  lower  curvature  at  a  point  to 
which  it  seldom  attains  under  normal  conditions.  Inflation,  therefore, 
should  be  moderate  and  barely  sufficient  to  project  the  visible  outline 
of  the  stomach  upon  the  abdominal  wall.  Inflation  to  a  greater  degree 
than  this  is  injurious  and  misleading.  As  a  control  auscultatory  per- 
cussion is  of  service. 

3.  The  most  accurate  method  of  all  is  naturally  the  .r-ray  examina- 
tion, but  it  is  inapplicable  unfortunately  as  a  routine.  The  outline  and 
position  of  the  stomach  in  health  and  in  disease  have  been  shown 
by  the  .r-ray  to  be  dift'erent  from  what  w^e  were  formerly  led  to 
suppose. 

Splashing  on  light  percussion  are  more  easily  elicited  in  gastroptosis 
than  in  simple  atony,  because  a  greater  portion  of  the  stomach  comes 
into  direct  contact  with  the  abdominal  wall.    The  diagnostic  significance 


PLATE    XIV 


Fig.    2 


Fig.    1. — Verlieally    Placed    Stomach    of   a    Child,    Twelve    Years    of 
with  the   Enteroptic   Habitus.       (Radiologist,    Dr.    Learning.) 

Fig.    2. — Gastroptosis  without  Atony.       (Radiologist,   Dr.    Le  Wald.) 


Age, 


Fig.    3 


Fig.    4 


Gastroptosis  -with   Moderate  Atony. 
(Radiologist,    Dr.   Leaniiing.) 


Gastroptosis  -with  Marked  Degree  of 
Atony.     (Radiologist,  Dr.  Learning.) 


DIAGNOSIS  OF  GASTHOPTOSIS  443 

of  suc'cussion  has  been  fully  described  under  the  heading  of  Atony, 
page  319. 

No  evidence  of  increased  peristalsis  can  be  obtained  in  uncomplicated 
gastroptosis,  and  the  absence  of  these  physical  signs  seem  somewhat 
to  disprove  the  idea  that  in  gastroptosis  mesenteric  constriction  or 
duodenal  kinks  produce  a  definite  obstruction  to  the  onward  passage 
of  the  stomach  contents.  A  certain  peristaltic  unrest  may  occasionally 
be  observed  in  thin  subjects  with  greatly  relaxed  abdominal  wall  and 
is  distinguished  from  an  increased  peristalsis  by  the  small  size  of  the 
waves  that  rise  and  fall,  and  by  the  absence  of  the  stately  march  from 
left  to  right. 

The  abdominal  aorta  is  usually  felt  pulsating  forcibly  in  the  epi- 
gastrium, although  no  lateral  expansion  is  observed  as  in  aneurysm. 
A  systolic  murmur  is  often  audible,  which  may  be  transmitted  down- 
ward and  heard  in  the  femoral  vessels.  Tenderness  over  the  aorta  is 
usually  quite  marked,  especially  when  pressure  is  made  over  the  celiac 
plexus  just  above  the  umbilicus  and  a  little  to  the  left  of  the  median 
line.    . 

Corroborative  evidence  is  afforded  by  demonstrable  ptoses  of  other 
organs,  especially  the  kidney  and  colon.  The  lower  pole  of  the  right 
kidney  is  normally  palpable  in  the  majority  of  women,  and  it  is  only 
when  the  greater  part  of  the  organ  is  palpable  that  an  actual  patho- 
logical nephroptosis  is  present.  Coloptosis  may  be  demonstrated  by 
the  inflation  of  the  colon  by  air  or  by  locating,  after  the  injection  of 
water,  succussion  sounds  below  the  lower  curvature  of  the  stomach 
that  has  previously  been  located  by  other  means. 

For  this  test  to  be  of  any  service  an  examination  of  the  colon  should 
be  made  when  the  stomach  is  empty,  so  that  no  confusion  may  be  caused 
by  the  presence  of  succussion  sounds  in  the  colon  and  stomach  at  the 
same  time.    The  most  certain  test  is  by  the  a:-rays. 

Diagnosis. — Gastric  Analysis. — Fasting  Stomach. — The  fasting  stomach 
in  gastroptosis  should  regularly  be  empty.  Food-stasis  and  fasting 
hypersecretions  are  not  observed  unless  complications  be  present.  In 
200  cases  of  the  disorder  in  which  examination  of  the  fasting  stomach 
was  made  in  gastroptosis  there  were  found  in  the  fasting  stomach: 

0  to    25  c.c.  of  fluid  in 173  cases 

25  to    50  c.c.  of  fluid  in 19  cases 

50  to    75  c.c.  of  fluid  in 4  cases 

75  to  100  c.c.  of  fluid  in 3  cases 

100  to  125  c.c.  of  fluid  in 1  case 

In  over  one-half  of  the  cases  in  which  an  amount  of  fluid  over  50  c.c. 
was  obtained  the  existence  of  chronic  appendicitis  could  be  demon- 


444  GASTROPTOSIS 

strated,  and  in  a  number  of  these  from  whom  the  appendix  was  removed, 
the  hypersecretion  was  not  observed  after  the  oj)eration,  indicating 
that  it  took  its  origin  from  pylorospasm,  depen(Ung  upon  the  apj)endix 
rather  than  due  to  the  gastroptosis  itself.  That  the  slight  amount  of 
hypersecretion  observed  in  some  of  the  cases  was  not  due  to  the  gastro- 
ptosis itself  seems  to  be  proved  by  the  writer's  analysis  of  100  cases 
of  gastroptosis  divided  into  3  groups  of  slight,  moderate,  and  marked 
degrees  of  atony. 

Examination-  of  Fasting  Stomach  in  Gastroptosis  with  Varying 
Degrees  of  Atony 

f     0  to  25  c.c,  36  cases 

1.  Slight  atony,  38  cases j    25  to  50  c.c,     1  case 

[  50  to  75  c.c,    1  case 

10  to  25  c.c,  38  cases 
25  to  50  c.c,    4  cases 
50  to  75  c.c,    2  cases 
I     0  to  25  c.c,  37  cases 

3.  Marked  atony,  39  cases '    25  to  50  cc,    2  cases 

I    50  to  75  cc,    0  cases 

It  would,  therefore,  seem  quite  conclusive  that  atony,  which  is  the 
primary  essential  of  gastroptosis,  does  not  influence  in  the  least  the 
conditions  of  the  fasting  stomach,  nor  does  it  appear  that  obstructive 
lesions  ascribed  to  the  descent  of  the  stomach  and  intestines,  such  as 
mesenteric  traction  and  duodenal  kinks,  are  sufficiently  obstructive, 
if  obstructive  at  all,  to  alter  the  condition  of  the  fasting  state. 

Test  Breakfast. — Test  breakfast,  as  a  rule,  is  well  digested,  of  homo- 
geneous consistency,  and  without  demonstrable  signs  of  gastric  catarrh. 
The  general  appearance  of  the  contents  is  that  of  atony,  often  slightly 
more  abundant  than  normal,  and  settling  on  standing  into  two  layers, 
the  liquid  stratum  not  being  more  than  equal  the  depth  of  the  sedimen- 
tary deposits  of  breadstuffs.  The  acidity  is  normal  or  slightly  acid  in 
over  four-fifths  of  the  cases,  as  is  shown  by  the  result  of  the  writer's 
examinations  in  250  cases. 

Achylia  was  present  in 9.5  per  cent. 

Subacidity  was  present  in 8.0  per  cent. 

Normal  acidity  was  pre.sent  in 55.6  per  cent. 

Hyperacidity  was  pre.sent  in 27.4  per  cent. 

The  acidity  in  gastroptosis  depends  largely  upon  the  degree  of  the 
associated  atony,  the  more  marked  the  atony  the  greater  is  the  tendency 
toward  hyperacidity.     In  the  writer's  series: 


TREATMENT  OF  GASTROPTOSIS  445 

In  gastroptosis  with  subacidity,  atony  was  marked  in  |  of  the  cases 

In  gastroptosis  with  normal  acidity,  atony  was  marked  in  5  of  the  cases 

In  gastroptosis  with  hyperacidity,  atony  was  marked  in  f  of  the  cases 

The  proportion  of  cases  complicated  by  achylia,  9.5  per  cent,  may  at 
first  sight  seem  rather  large,  and  may  suggest  that  gastroptosis  pre- 
disposes toward  such  a  reduction  of  gastric  acidity.  Achylia  in  the 
writer's  experience  occurs,  howe^'er,  in  nearly  7  per  cent,  of  all  patients 
applying  for  relief  of  gastro-intestinal  disorders.  According  to  these 
figures  achylia  would  naturally  complicate  7  per  cent,  of  the  gastrop- 
tosis cases.  As  a  matter  of  fact  it  complicates  but  9.5  per  cent.,  the 
difference  being  so  slight  as  to  make  a  causal  relationship  between 
the  two  diseases  highly  improbable. 

Prognosis. — The  prognosis  is  good  for  the  prolongation  of  life  and 
good  for  a  reasonable  degree  of  well-being  to  enable  the  patient  to  live 
his  allotted  life  with  comparative  comfort.  Much  depends,  however, 
upon  the  ability  of  the  patient  to  live  within  physical  and  nervous 
limitations.  Enteroptotic  individuals  who  are  congenitally  neuras- 
thenic can  never  hope  to  be  robust  and  of  good  endurance,  but  they 
will  suffer  from  their  digestion  whenever  they  run  down  from  any 
cause  whatever.  The  prognosis  in  such  cases  naturally  depends  upon 
the  ability  of  the  patient  so  to  adapt  his  life  that  his  meagre  nervous 
and  physical  resources  are  conserved  rather  than  wasted.  Under 
proper  hygiene  and  treatment  results  are  often  obtained  that  are  sat- 
isfactory to  the  physician  and  patient  alike,  and  occasionally  the 
result  is  both  brilliant  and  lasting. 

Treatment. — Prophylactic  Treatment. — It  must  be  recognized  that 
gastroptosis  may  exist  without  symptoms  until  the  stomach  becomes 
atonic.  The  prophylactic  treatment  is  therefore  directed  toward  the 
prevention  of  atony.  Those  individuals  with  the  enteroptotic  habitus 
are  by  nature  unable  to  stand  the  storm  and  stress  of  life,  and  therefore 
not  only  should  they  be  spared  as  far  as  possible  excessive  physical 
strains  and  long  strenuous  hours  of  work,  but  by  outdoor  life  and  ample 
amounts  of  rest  and  sleep  they  are  to  be  built  up  and  rendered  hardy 
and  more  resistant  to  the  demands  of  daily  life.  Especially  is  this 
prophylactic  treatment  indicated  in  enteroptotic  children  during  their 
years  of  rapid  growth  and  development.  Excessive  water-drinking  at 
meals  should  be  prohibited.  The  daily  work  should  not  be  resumed 
after  acute  illness  until  the  full  strength  has  returned.  After  child- 
birth, rest  in  bed  should  be  enforced  for  a  much  longer  period  of  time 
than  in  normal  individuals,  so  as  to  allow  the  abdominal  walls  to 
regain  their  tone,  and  upon  convalescence  a  well-fitting  abdominal  belt 
should  be  worn  for  at  least  six  months. 


446  GASTROPTOSIS 

Medical  Treatment. — The  medical  treatment  is  devised  to  meet  three 
indications: 

1.  To  conserve  the  muscular  lack  of  tone  and  overdistention  of  the 
atonic  stomach  by  diet,  rest,  and  abdominal  support. 

2.  To  produce  a  gain  in  weight. 

3.  To  counteract  the  neurasthenic  state. 

Either  an  ambulant  or  a  rest  cure  treatment  may  be  indicated. 

Ambulant  Treatment. — If  the  symptoms  are  not  severe  and  not 
attended  by  marked  loss  of  flesh  and  strength,  it  may  be  possible  to 
effect  a  cure  while  the  patient  is  up  and  around.  The  ambulant  treat- 
ment may  also  be  tried  when  the  circumstances  of  the  case  or  the 
inclinations  of  the  patient  render  a  rest  cure  impossible  or  inexpedient 
for  the  time  being.  It  is  well,  however,  to  explain  to  the  patient  that 
such  a  treatment  is  but  experimental  and  that  a  rest  cure  regime  may 
become  necessary  in  case  of  failure. 

Dietetic  Treatment. — The  diet  is  that  of  atony.  The  main  indication 
is  to  reduce  the  mechanical  bulk  taken  at  any  one  meal  and  to  divide 
the  food  into  small  quantities  taken  at  more  frequent  intervals.  Liquids 
should  be  taken  sparingly  at  the  meals  although  they  may  be  taken  in 
the  times  between,  in  doses  sufficient  to  assuage  thirst,  provided  that 
more  than  one-half  glass  is  not  taken  at  any  one  time.  The  diet  should 
be  varied  and  individual  tastes  should  be  consulted  as  far  as  possible, 
as  the  tendency  always  is  for  these  patients  to  eat  too  little  rather  than 
to  eat  too  much.  Too  much  attention  should  not  be  paid  to  foolish 
whims  and  fancies  which  result  in  the  cutting  down  of  the  diet  to  a  starva- 
tion-point. An  increase  in  fats  is  usually  desirable.  Fresh  butter  and 
cream  are  to  be  advised,  or  Russell's  emulsion  may  be  given.  As  the 
digestive  power  of  the  stomach  is  usually  good,  the  quality  of  food  may 
be  varied,  but  should  achylia  exist,  red  meats  should  be  reduced,  with 
a  corresponding  increase  in  the  carbohydrates  and  fats.  A  simple 
diet  for  gastroptosis  is  as  follows: 

Breakfast. — A Uoived:  Cup  of  coffee  or  cocoa ,  with  cream  and  sugar. 
Saccharin  may  be  used  instead  of  sugar  if  preferred.  Cereal  with 
cream  and  sugar.  Two  soft-boiled  or  poached  eggs  or  minced  chicken. 
Rolls,  toast,  pulled  bread,  or  zwiebach.  Maximum  amount  of  butter, 
preferably  unsalted.  Strained  honey,  such  as  Sheffield  Farms.  Orange 
marmalade  or  any  Dundee  jam. 
None:     No  hot  bread;  no  fruit. 

10  to  11  A.M. — Choice  of:  Glass  of  top  milk  or  cream,  or  milk  and 
cream,  and  crackers.  Cup  custard;  junket;  egg  shake  or  raw  eggs; 
chicken  sandwich;  malted  milk;  buttermilk  or  lactone  milk;  Russell's 
emulsion. 


TREATMENT  OF  GASTROPTOSIS  447 

Luncheon. —  None:  No  soup.  Liquids  restricted  to  less  than  one 
glass.  No  steak,  roast  beef,  pork,  salt  fish,  or  shell-fish.  No  sweet- 
breads or  kidneys.    No  radishes,  raw  celery,  or  anchovy. 

Alloived:    Caviar,  olives. 

Choice  of:  Fresh  fish,  chicken,  lamb,  mutton,  simply  prepared 
ragout;  oysters  in  any  form;  fowl  of  all  kinds  except  domestic  duck 
or  goose;  lean  broiled  or  boiled  ham. 

Freely:  Peas,  beans,  spinach,  samp,  rice,  macaroni,  spaghetti, 
with  cheese  if  preferred.  Any  vegetable  that  may  be  put  through  a 
puree  sieve,  such  as  turnips,  carrots,  etc.  Potatoes  may  be  taken  in 
any  form  but  fried;  boiled  potatoes  to  be  taken  very  occasionally  and 
then  thoroughly  masticated.  Boiled  onions,  tender  beets,  and  oyster 
plant. 

Occasionally:  Cauliflower,  Brussels  sprouts,  stew^ed  celery,  arti- 
choke, asparagus  tips.    Salad  with  French  dressing. 

Dessert. — Choice  of:  Rice  pudding,  farina,  corn-starch,  blanc- 
mange, prune  souflSe,  tapioca;  ice-cream,  but  no  fruit  ices;  baked  apple 
with  cream;  stewed  figs  and  prunes. 

Occasionally:     Simple  cake,  such  as  pound  cake,  sponge  cake,  etc. 

None:     No  oranges  or  grape  fruit  or  raw  apples. 

Allowed:  Cream  cheese,  Roquefort,  Camembert,  Brie,  Neufchatel, 
or  pot  cheese. 

4  P.M. — Same  variety  as  11  a.m.,  with  the  additional  choice  of  cocoa 
or  chocolate  with  cream  and  sugar;  or  a  farinaceous  dessert,  such  as  on 
luncheon  list. 

Dinner. — Same  variety  as  for  luncheon. 

While  liquids  are  restricted  at  meals,  water  may  be  freely  taken 
between  meals. 

Drug  Treatment. — During  the  early  part  of  the  treatment  patients 
are  usually  keyed  up  and  on  high  tension,  and  the  writer  has  found  it 
desirable  in  almost  every  case  to  reduce  this  excitable  nervous  state 
by  suitable  medication. 

Of  all  forms  of  soothing  medication,  the  following  prescription  has 
proved  the  most  serviceable,  and  the  writer  employs  it  almost  as  a 
routine  measure  in  his  cases. 

I^ — Resorcin  resublimat.  (Merck) 5j 

Chloral  hydrat 3ss 

Strontii  bromid 3iiss 

Aq.  chloroform giv 

Spirits  anise gtt.  viij 

M.     Sig. — Teaspoonful  in  a  wineglass  of  water  three  times  a  day  after  eating. 

After  about  a  week  a  change  should  be  made  to  a  more  stimu- 
lating form  of  treatment,  of  which  nux  vomica  or  physostigma  is  the 


448  (lASTROPTOSIS 

essential    feature.      The    folluwiiig    prescriptions    have    been     found 
serviceable : 

I^ — Tinct.  physostigma, 

Tinct.  nucis  vomicae aa     3iiss 

Sodii  glycerophosphate 5v 

Glycerols  diazyme  (Fairchildj  5iv 

Aquae ad     S^iij 

M.    Sig. — Dessertspoonful  in  a  little  water  three  times  a  day  after  eating. 

I^ — -Tinct.  nucis  vomicae 5v 

Elxir  calisaya ad     giv 

M.    Sig. — Tea.spoonful  in  water  after  eating  three  times  a  day. 

I^ — Eserine gr-  rn 

Ferri  et  quin.  citrat gr.  iij 

Calcii  glycerophosphate .     gr.  vij 

M.  ft.  caps.  no.  j.     Dentur  tales  doses,  no.  .\xxiv. 

Sig. — One  capsule  three  times  a  day  after  eating. 

It  is  unwise,  h()\ve\'er,  to  make  the  change  of  treatment  too  suddenly. 
The  writer  recommends  that  for  three  days  one  of  the  nux  vomica 
preparations  be  given  after  breakfast  and  the  bromide  mixture  after 
lunch  and  dinner;  that  for  the  next  three  days  the  nux  vomica  be  given 
after  breakfast  and  lunch,  the  bromide  after  dinner  alone,  and  for  the 
next  three  days,  three  doses  of  the  nux  vomica  preparation  be  given 
after  meals,  while  the  bromide  is  to  be  given  at  bedtime.  This  latter 
combination  may  be  continued  for  at  least  two  months.  During  the 
early  part  of  the  treatment  the  bowels  should  be  opened,  preferably 
by  a  saline  having  a  cholagogue  effect.  The  following  prescription 
has  been  found  serviceable: 

I^ — Sodii  benzoat 5.1 

Sodii  salicylat '■  3ij 

Sodii  sulphat 3vj 

Magnesii  sulphat 3xj 

Tinct.  nucis  vomicae 3ss 

Aquae oviij 

M.     Sig. — Tablespoonful  in  three-fourths  of  a  glass  of  water  on  rising. 

Eliervescing  sodium  ph()S})liate  nia\'  be  achiscd.  The  dose  of  the 
aperient  should  be  so  regulated  so  that  no  more  than  one  liquid  or  two 
semiformed  moAements  result.  Should  auto-intoxication  sym])toms  be 
prominent,  intestinal  irrigations  two  or  three  times  a  week  may  be 
useful.  The  teehni(iue  of  the  ])roper  form  of  irrigation  is  given  under 
Atouy  on  page  .'^);)1 . 

After  the  bowels  iia\e  been  regulated  by  the  saline,  laxative  articles 
of  diet  should  be  added  and  the  dose  of  th(>  ajxTient  gradually  reduced. 
Stewed  fruit  at  or  iifter  the  meals  (uexcr  before)  or  one-half  a  wine- 


TREATMENT  OE  (lASTROPTOSIS 


449 


glassful  of  olive  oil  or  paraffin  oil  at  bedtime,  or  the  increase  of  sugar, 
especially  of  lactose,  may  be  found  serviceable.  The  more  sugar  of 
milk  can  be  worked  into  the  diet  the  better.  C'oarse  breads  and  the 
use  of  bran  in  biscuits  or  in  the  form  of  bran  cakes  are  serviceable 


Fig,  89 


Author's  belt  for  enteroptosis.     The  uplift  is  to  be  especially  noted. 


in  increasing  peristalsis.  Peristaltic  hormone  may  be  given  either  by 
mouth  or  by  intermuscular  injection,  and  either  is  noticeably  efficacious 
or  absolutely  disappointing. 

Hygienic  Treatment. — Patients  should  not  exercise  if  they  can  help 
it  directly  after  eating.    Two  hours'  rest  in  bed  during  the  day  is  always 
29 


450 


GASTROPTOSIS 


advisable,  and  is  generally  possible  if  the  patient  so  wills  it  to  be.  The 
best  hours  for  rest  are  directly  after  lunch,  but  in  the  short  afternoons 
of  winter  the  rest  may  be  taken  before  dinner.  A  tight-fitting  abdominal 
belt,  or  a  corset  that  exerts  a  belt-like  pressure  on  the  lower  abdomen, 
leaving  ample  space  above  for  deep  respiration,  is  of  service  in  almost 


Fig.  90 


Ordinary  abdominal  belt,  not  to  be  advised  as  it  has  no  uplifting  effort. 

all  the  cases,  not  only  because  of  the  sup})ort  which  it  gives  to  pro- 
lapsed viscera,  but  because  counter-pressure  upon  the  abdomen  prevents, 
to  some  extent  at  least,  the  baneful  effects  of  gravity  in  producing  a 
lowered  blood  pressure  when  the  patient  stands.  The  ])hysician  should 
personally  see  to  it  that  the  belt  is  well-fitting  and  serves  its  ])urpose. 
The  majority  of  Ix-lts  in  the  market  are  practically  broad  elastic  belts 


TREATMENT  OF  GASTROPTOSIS 


451 


about  the  hips,  pressing  backward  upon  the  abdominal  wall  without 
any  traction  upward.  The  belt  used  by  the  writer  is  so  constructed 
that  it  lies  low  in  front  and  rises  high  in  the  back,  so  that  the  pressure 
is  not  only  backward  but  upward.  Perineal  straps  seem  to  be  a  necessity, 
as  otherwise  the  belt  rides  up  in  front  and  exerts  no  upward  traction. 


Good  straight  front  corset.     To  be  recommended. 


The  belt  should  be  adjusted  before  the  patient  rises  in  the  morning, 
so  as  to  retain  the  organs  as  far  as  possible  in  the  position  which  they 
assume  during  recumbency,  and  the  belt  should  be  worn  continuously 


1  This  corset  is  made  by  Mine.  Rosso,  27  W.  36th  St.,  New  York  City, 


452  GASTROPTOSIS 

during  the  day.     If  the  belt  be  well-fitting  the  use  of  objectionable 
hernia  pads  may  be  avoided. 

A  variety  of  corsets  may  be  employed,  some  of  the  simple  straight 
front  variety  and  others  with  an  inner  belt  of  elastic  webbing. 

Fig.  92 


Conil)inatioii  forsft,  showing  inner  elastic  belt  attarlicd   to  the  side  of  ;i  straight  front   corset. 

Mechanical  su])port  of  the  stomach  by  adhesive  strapping  is  of 
.service  for  short  periods  of  time,  but  naturally  cannot  l)e  long  con- 
tinued. Tiic  best  method  of  adhesive  strai)])ing  must  be  credited  to 
Dr.  Achilles  Rose. 

For  the  api)lication  of  a  Kosc  belt  a  yard  stri|)  7  inches  wide  of  ZO 
adhesive  moleskin  phtster  is  to  be  used,  and  cut  in  three  ])ieces,  as 
shown  in  Fig.  i)4.     The  piece  marked  /  is  first  to  be  a])[)lied,  the  apex 


TREATMENT  OF  GASTROPTOSIS 


453 


Fig.  93 


Combination  corset.     The  straight  front  corset  is  fastened.     The  minor  elastic  belt  shown  in  the 
preceding  photograph  is  fastened  at  the  side  by  the  tape.'^ 

Fig.   94 


Rose's  belt. 

1  This  belt  is  made  by  Mme.  Ros.so,  27  West  Sfitli  St.,  New  Y(uk  City. 


454 


GASTROPTOSIS 


lying  just  above  the  symphysis,  the  ends  passing  upward  and  over- 
lapping in  the  small  of  the  back.  The  pieces  //  and  ///  are  then  to 
be  applied  as  shown  in  Fig.  95. 

A  simple  method  for  mechanical  treatment  is  advised  by  McCaskey.^ 
The  hair  on  the  pubes  having  been  shaved,  a  strip  of  zinc  oxide  adhesive 


Fig.  95 


Hose's  holt  as  applied. 

plaster,  2  or  2^  inches  wide  and  5  or  (>  inches  long,  is  placed  transversely 
across  the  extreme  lower  abdomen  as  near  as  possible  to  the  pubes. 
To  each  end  of  this  strap  is  attached  a  bandage  of  about  the  same 
width,  long  enough  to  pass  around  tlu'  body  abo\'e  the  iliac  crest,  and 
there  be  tied  or  otherwise  fastened.    If  tlie  ends  of  the  j)laster  become 


'  Jour.  Amor.  Mod.  Assoc,  October  28,  1911. 


TREATMENT  OF  GASTROPTOSIS  455 

loosened  and  pulls  up  by  traction  of  the  bandage,  narrow  vertical 
strips  of  plaster  may  be  applied  across  each  end  of  the  adhesive  strap 
and  applied  to  the  skin  above  and  below.  The  bandage  is  well  padded 
with  cotton  so  as  to  prevent  irritation  of  the  skin  beneath  it  and  to 
permit  of  its  being  drawn  as  tightly  as  possible  to  furnish  the  necessary 
support  from  below. 

Under  the  ambulant  treatment  just  described,  a  gain  in  weight  is 
the  main  indication  that  the  treatment  is  beneficial.  If  the  patient 
does  not  gain  within  six  weeks  there  is  very  little  use  in  going  on  with 
the  case  while  the  patient  is  up  and  about,  but  as  long  as  the  gain  con- 
tinues the  treatment  may  be  persisted  in.  Some  patients  do  not  gain 
at  all,  others  gain  for  a  time  and  then  relapse,  so  that  at  the  end  of 
three  months  they  are  no  better  than  when  they  started.  For  these 
patients  nothing  but  a  rest  cure  will  be  of  service. 

Fig.   96 


A  device  for  the  mechanical  treatment  of  Glenard'a  disease.     A,  double-padded  bandage; 
B,  zinc  oxide  strip.     (McCaskey.) 

Rest  Cure  Treatment. — A  rest  cure  treatment  with  forced  feeding  is 
indicated  in  all  cases  with  aggravated  symptoms  attended  by  an  extreme 
loss  of  flesh  and  strength  and  in  all  other  cases  in  which  the  ambulant 
treatment  has  not  been  followed  by  a  progressive  gain  in  weight. 
Many  patients  suffer  from  the  mechanical  overdistention  of  the  stomach 
by  food  when  they  are  sitting  or  standing,  and  consequently  cannot 
eat  enough  with  comfort  to  gain  in  flesh  and  strength,  but  they  can  eat 
a  sufficient  quantity  while  they  are  in  bed.  In  other  cases  nervous 
symptoms  induced  by  a  lowered  blood  pressure  on  standing  are  con- 
trolled by  prolonged  recumbency.  The  patient  should  be  kept  in  bed 
for  at  least  four  weeks,  rarely  over  that  time.  The  services  of  a  tactful 
and  congenial  nurse  are  almost  essential  for  good  results  of  the  treat- 
ment. Semi-isolation  should  be  insisted  upon.  Congenial,  cheerful 
friends  are  usually  better  than  oversympathetic  relatives,  but  as  it 
is  difficult  to  draw  the  line,  the  fewer  that  see  the  patient  the  better. 
The  patient  may  go  to  the  toilet  or  sit  up  while  the  room  is  prepared, 


456  riASTROPTOSlS 

but  at  otluT  times  siiould  remain  in  hed.     Except  at  meals  more  than 
two  pillows  should  not  be  allowed. 

During  the  first  two  weeks  hot  applications  should  be  applied  to  the 
abdomen,  either  in  the  form  of  the  Priesnitz  umschlag  or  the  electric 
pad,  under  which  should  be  placed  one  layer  of  damp  flannel.  The 
monotony  of  the  afternoon  may  be  broken  by  a  hot  drip  sheet  for  a 
half-hour  followed  by  a  cold  spinal  sponge  and  an  alcohol  rub. 

The  diet  and  the  medication  are  the  same  as  in  the  ambulant  form. 
Some  of  the  patients,  especially  those  who  have  been  unable  hitherto 
to  take  sufficient  nourishment  without  discomfort,  may  complain  of 
the  increased  quantity  of  food  which  they  are  obliged  to  take,  and  it 
may  be  that  they  are  more  uncomfortable  imder  the  full  diet  than  they 
were  before  the  treatment  began.  Under  these  circumstances  it  is 
well  to  cut  down  the  quantities  l^ut  to  continue  with  the  varied  quality 
of  the  meals  indicated  in  the  diet  list.  After  about  a  week  the  quantity 
can  be  gradually  increased. 

Intragastric  faradization  may  be  tried  in  those  who  are  peculiarly 
susceptible  to  the  good  efi'ects  of  suggestive  treatment.  It  serves  to 
relieve  monotony  and  to  exercise  the  abdominal  wall,  but  its  actual 
value  in  curing  atony  is  very  problematical.  A  scheme  for  the  day 
that  has  been  found  by  the  writer  to  be  practical  is  as  follows: 

7.45  A.M.     Glass  of  water  or  saline  draft.     Wash  hands  and  face, 
clean  teeth,  change  hot  a])plications. 

Breakfast, 

Rest. 

Stroking  massage  to  the  abdomen. 

Intestinal  irrigation. 

Warm  pad;  cold  spinal  douche;  make  the  bed. 

Nourishment. 

Rest. 

Lunch. 

Rest  alone;  nurse  goes  out. 

Abdominal  massage,  stroking  or  circling  movements,  or 
intragastric  faradization. 

Nourishment. 

Drip  sheet;  cold  spinal  sjjonge;  alcohol  rub. 

Diimer. 

Cieneral  massage. 

Wash  hands  and  face;  make  the  bed  for  the  night. 

Nourishment;  clean  teeth. 

Lights  out. 

Hot  applications  changed  every  two  hours  in  the  day  and  left  on 
all  night. 


8.15 

A.M. 

8.30 

A.M. 

9.30 

A.M. 

9.45 

A.M. 

10.45 

A.M. 

11.00 

A.M. 

11.00 

A.M. 

1.00 

P.M. 

2.00 

P.M. 

4.00 

P.M. 

4.30 

P.M. 

6.00 

P.M. 

7.00 

P.M. 

8.15 

P.M. 

9.15 

P.M. 

9.30 

P.M. 

9.45 

P.M. 

TREATMENT  OF  fiAST h'O/'TOS/S  407 

'^riic  first  siii'ii  of  iiiiproNciiu'iit  hy  such  ;i  (real incut  is  a  f;aiii  in  wciulit, 
and  the  weight  curxe  l'()lh)\vs  one  or  two  types.  (Jain  in  \veii;ht  iJia\-  Ije 
progressive  from  the  start,  a\'eraginf^  fretpiently  one-haU*  i)oinul  a  rhiy, 
occasionally  (lroi)pini>;  a  little,  and  usually  reniaiiiiuf;-  stationary  during 
the  menstrual  jjeriod.  When  the  patient  reassumes  family  life  at  the 
termination  of  the  rest  cure,  there  is  often  a  fall  in  weight  and  a  return 
of  the  old  symptoms;  hut  the  relapse  is  temporary,  and  is  succeeded 
by  a  further  progressive  gain.  In  other  cases  it  may  be  almost  impossible 
during  the  rest  cure  for  the  patient  to  gain  much  weight,  so  that  at 
the  end  of  the  four  weeks  he  may  be  but  2  or  8  pounds  heavier  than 
at  the  start.  The  temporary  loss  of  weight  usually  occurs  at  the  end 
of  the  treatment,  so  that  the  patient  loses  what  he  has  gained,  but 
succeeding  this,  there  is  a  progressive  gain  which  may  ultimately  be  as 
great  as  that  observed  in  the  first  set  of  cases. 

The  patients  should  always  be  warned  of  the  probable  return  of  their 
symptoms  during  the  week  following  the  termination  of  the  rest  cure. 

About  every  ten  days  during  the  period  of  forced  feeding  patients 
complain  of  "feeling  bilious."  The  tongue  is  coated,  the  breath  offen- 
sive, and  the  appetite  fails.  These  symptoms  are  readily  controlled 
by  small  doses  of  calomel,  or  by  the  following  prescription: 

I^ — Massae  hydrarg., 

Ext.  leptandra, 

Bile  salts  (Fairchild) aa     gr.  ^ 

M.  ft.  caps.  no.  j. 

Sig. — One  three  times  a  day  for  three  days. 

Succeeding  the  rest  cure  the  patients  should  follow  the  rules  of 
management  laid  down  in  the  ambulant  form  of  treatment  and  should 
be  under  observation  for  at  least  six  months.  Systematic  weight 
records  should  be  made  and  the  causes  for  any  loss  should  be  ascertained. 

Surgical  Treatment. — To  the  surgeon  the  displacement  of  the  stomach 
is  a  matter  of  prime  importance,  and  there  are  those  who  advocate 
surgical  measures  to  restore  the  stomach  to  its  proper  place  and  at 
the  same  time  to  correct  in  some  instances  the  results  of  duodenal  or 
intestinal  kinks  and  stasis  by  appropriate  means.  Beyea  was  among 
the  first  in  this  country  to  perform  the  operation  of  suturing  the  gastro- 
hepatic  omentum  to  secure  elevation  of  the  stomach,  and  has  treated 
26  cases  in  this  way,  all  of  which  had  resisted  skilled  medical  treatment. 
Beyea  takes  the  conservative  stand  that  the  operation  should  be  done 
only  when  other  treatment  falls  short  of  a  cure.  Ilovsing^  is  a  more 
enthusiastic  advocate  of  the  operation,  having  an  experience  of  over 

'  Jour.  Amer.  M(>(1.  Assoc,  lix,  Xo.  5,  p.  ,334. 


458  GASTROPTOSIS 

1()3  cases  in  which  gastropexy  was  done.  In  his  series  hepatopexy 
was  done  in  68,  and  in  4  cases  it  was  necessary  to  resect  part  of  the  left 
lobe  of  the  liver  in  order  to  gain  access  to  the  gastrohepatic  omentum. 
In  10  of  the  cases  secondary  unilateral  or  bilateral  nephropexy  was 
necessary  before  an  absolute  result  could  be  obtained. 

Rovsing  anchors  the  upper  line  of  the  stomach  by  leading  strong 
silk  sutures  on  the  serous  coat  of  the  stomach  parallel  with  the  lesser 
curvature  through  the  anterior  abdominal  wall,  so  that  the  stomach 
lies  flat  against  the  abdominal  parietes  without  shrinkage  or  folding, 
thus  obtaining  a  perfectly  secure  and  solid  adhesion.  Rovsing  has 
collected  the  reports  of  93  additional  operations  performed  by  Scandi- 
navian surgeons  according  to  his  technique,  and  adding  these  results 
to  the  163  cases  of  his  own  has  tabulated  the  end  results  in  the  256 
cases  as  follows: 

Cure 63.2  per  cent. 

Great  improvement 12.8  per  cent. 

Improvement 7.0  per  cent. 

Slight  improvemtuit  or  no  cliange 12.8  per  cent. 

Deaths -   .  4.6  per  cent. 

Gastrojejunostomy  formerly  in  vogue  in  the  hands  of  a  few  surgeons 
in  the  treatment  of  gastroptosis  has  been  entirely  abandoned  for  the 
reason  that  in  this  condition  pyloric  or  duodenal  obstruction  does  not 
occur,  and  there  is,  therefore,  no  reason  for  performing  the  operation. 
Of  late  surgery  has  grown  more  radical  in  the  treatment  of  these  cases. 
Not  only  is  gastropexy  advised,  but  partial  gastrectomy  with  anastomosis 
of  the  duodenum  to  the  stomach,  resection  of  the  colon  in  whole  or  in 
part,  or  ileocolostomy  are  being  recommended.  To  this  radical  surgery 
the  writer  takes  exception.  An  experience  of  a  little  over  600  cases  in 
private  practice  in  which  the  disease  was  treated  medically,  seems  to 
him  to  indicate  that  the  end-results  obtained  are  immeasurably  better 
than  those  recorded  by  Rovsing  in  his  surgical  patients.  It  is  not  the 
displac-ement  of  the  stomach  that  produces  the  symptoms,  it  is  the 
atony  to  which  it  is  predisposed,  and  the  atony  can  be  more  readily 
treated  by  medical  than  by  surgical  means.  Unless  the  mortality  rate 
can  be  reduced  from  Rovsing's  figures,  surgery  is  not  lightly  to  be 
advised. 

Any  operation  ])erformed  on  a  patient  with  visceral  ptoses  and  the 
enteroptotic  habitus  is  apt  to  change  a  latent  neurasthenic  into  an 
active  one. 


CHAPTER  XVII 
HYPERACIDITY 

IIypp:racidity  may  be  defined  as  an  abnormal  increase  in  h\'dro- 
chloric  acid  during  the  digesting  period,  the  phenomenon  disappearing 
as  soon  as  the  stomach  empties  itself.  The  term  is  unsatisfactory 
because  it  indicates  only  a  secondary  disturbance  of  the  stomach  which 
is  common  to  a  great  variety  of  disorders  both  organic  and  functional, 
acute  and  chronic.  It  is  as  indistinctive  as  "fever"  or  "bronchial 
breathing."  Cases  are  commonly  designated  as  hyperacidit}'  or  hyper- 
chlorhydria  that  are  really  examples  of  ulcer,  cancer,  muscular  insuffi- 
ciency, or  gall-bladder  or  appendicular  disease  without  any  attempt 
at  a  more  accurate  classification. 

Hyperacidity  is  to  be  sharply  differentiated  from  hypersecretion. 
In  hyperacidity  the  percentage  of  acid  is  increased  without  increase 
in  the  quantity  of  fluid  secreted,  while  in  hypersecretion  the  whole 
quantity  of  gastric  juice  is  increased  over  and  above  that  required 
for  the  purposes  of  digestion,  either  during  the  digesting  period  alone 
(alimentary  secretion)  or  poured  out  as  well  at  times  when  the  stomach 
should  be  empty  (continuous  hypersecretion).  The  two  conditions  are 
often  combined;  the  majority  of  hypersecretions  are  hyperacid,  but 
on  the  other  hand  hyperacidity  exists  frequently  enough  without  any 
hypersecretion  at  all.  Again  we  must  sharply  differentiate  between  those 
cases  of  hyperacidity  that  are  due  to  recognized  forms  of  organic  dis- 
ease (secondary  hyperacidity)  from  those  instances  in  which  no  definite 
cause  for  the  hyperacidity  can  be  ascribed,  and  which  we  consider  by 
exclusion  to  be  of  functional  origin  (primary  hyperacidity).  Many 
glaring  errors  of  diagnosis  are  committed  by  classifying  together  a 
variety  of  diseases  having  only  this  one  symptom  of  hyperchlorhydria. 
Among  the  organic  causes  which  may  give  rise  to  secondary  hyper- 
acidity may  be  numerated: 

1.  Gastric  and  duodenal  ulcer. 

2.  Gastric  cancer. 

3.  Hyperacid  gastritis. 

4.  Pyloric  stenosis — benign,  malignant  or  spasmodic. 

5.  Irritative  lesions  of  the  gall-bladder  or  appendix.  In  addition 
to  these  organic  lesions  we  must  add 

0.  Gastric  myasthenia  or  atony — either  with  or  without  gastroptosis. 


460  HYPERACIDITY 

In  200  c()nsecuti\'e  cases  in  which  the  total  acidity  of  the  <;astric 
contents  after  the  Ewald  test  breakfast  was  70  or  oxer,  irrespective 
of  whether  hypersecretion  was  present  or  not,  the  foll()win,i>-  percentaijes 
were  found  for  the  various  causes  of  the  condition. 

Gastroptosis 20.5  per  cent. 

Ulcer 19.0  per  cent. 

Chronic  appendicitis 11.5  per  cent. 

Atony 11.0  per  cent. 

Diseases  of  the  gall-bladder 5.5  per  cent. 

Chronic  acid  gastritis 5.5  per  cent. 

Cancer 4.0  per  cent. 

Hypersecretion  of  unknown  origin 2,0  per  cent. 

Benign  pyloric  stenosis 1.0  per  cent. 

Unknown  or  functional 20.0  per  cent. 

Of  these  cases  21  per  cent,  were  accompanied  by  hypersecretion  while 
in  79  per  cent,  gastric  juice  was  not  secreted  in  abnormal  quantity  either 
in  the  fasting  or  in  the  digesting  state.  It  is  evident  that  to  call  all  these 
cases  hyperacidity  indicates  lack  of  knowledge  and  of  careful  efforts 
of  diagnosis  that  are  quite  inexcusable,  and  yet  this  is  what  is  happening 
every  day.  After  organic  causes  are  excluded  there  remain  a  number 
of  instances  in  which  no  definite  lesion  can  be  discovered  and  in  which 
the  cause  for  the  hyperacidity  remains  in  doubt.  In  our  present  state 
of  knowledge  we  are  forced  to  class  these  cases  as  of  functional  origin 
provided  that  we  do  not  regard  the  use  of  the  term  as  final  but  keep 
our  mind  open  and  our  senses  alert  to  make  a  better  diagnosis  in  time. 
The  diagnosis  of  hyperacidity  vmsf  always  he  a  provisional  one. 

Frequency. — The  frequency  of  hyperacidity  is  difficult  to  determine 
with  any  accuracy.  The  general  consensus  of  opinion  is  that  al)out 
one-half  the  dys})eptics  who  apply  for  treatment  suffer  from  this  dis- 
order. In  Germany,  Jaworski  found  hyperacidity  in  75  per  cent,  of 
all  patients  examined.  According  to  this  writer  it  is  most  commonly 
encountered  in  Polish  Jews.  In  New  York,  Einhorn  reports  50  per  cent, 
of  all  patients  examined  by  him  to  be  thus  affected.  Friedenwald, 
in  Baltimore,  found  hyperacidity  present  in  O.S  per  cent,  of  2000  private 
patients  examined.  In  France,  IVIatthieu  and  Uemond  report  the 
frequency  as  30  per  cent.,  Bouveret  as  25  per  cent.  On  the  other  hand, 
Fenwick,  in  England  claims  that  but  4.8  per  cent,  of  his  hospital  cases 
and  9.2  per  cent,  of  his  ])rivate  patients  show  hyperacidity.  In  the 
writer's  experience  17.4  per  cent,  of  private  patients  with  indigestion 
show  superacid  gastric  conditions  including  both  hyperacidity  and 
hypersecretion,  l)ut  that  only  13.8  per  cent  show  hyi)eracidity  without 
actual  increase  in  the  amount  of  gastric  juice  secreted.     His  experience 


FREQUENCY  OF  IIY I'EUACIUITY  4(U 

at  Bellevue  IT()si)ital  leads  him  to  the  conclusion  that  hyperacidity 
is  about  one-half  as  frequent  in  hospital  as  in  private  cases.  There 
are  several  reasons  for  these  differences  of  opinion  as  to  the  relative 
frequency  of  the  disorder. 

There  is  unfortunately  no  fixed  standard  of  gastric  acidity  tliat  is 
to  he  regarded  as  normal.  Some  observers  diagnostic  ite  hyperacidity 
whenever  the  total  acid  is  over  50,  others  only  when  the  acidity  runs  to 
GO  or  70,  while  many  writers  do  not  give  any  indication  at  all  as  to  what 
they  regard  as  the  dividing  line  between  acidity  that  is  normal  and  acid- 
ity that  is  excessive,  so  that  we  do  not  know  what  they  really  mean 
by  hyperacidity.  The  writer  believes  that  in  private  patients  coming 
from  New  York  and  the  adjacent  cities,  the  normal  limit  of  gastric 
acidity  ranges  from  50  to  70,  and  that  it  is  only  when  the  total  acidity 
runs  beyond  this  point  that  it  may  be  regarded  as  abnormal.  In  hos- 
pital practice  the  normal  acidity  is  somewhat  lower,  ranging  from  50 
to  00.  These  figures  apply  only  to  the  analyses  of  the  Ewald  test 
breakfast.  For  ordinary  meals  and  test  dinners  which  include  meat, 
at  least  10  points  must  be  added. 

There  are  undoubtedly  variations  in  gastric  acidity  in  different  places 
and  among  different  races,  due  not  alone  to  temperamental  and  racial 
peculiarities  but  also  to  environment,  to  variations  in  diet  and  to  the 
\'arying  frequency  of  organic  diseases  of  the  stomach,  such  as  acid 
gastritis  or  ulcer.  It  may  be  assumed  that  hyperacidity  is  most  common 
in  Germany  and  the  Northern  European  countries,  less  so  in  France, 
while  in  England  and  the  United  States  the  disorder  is  comparatively 
infrequent. 

In  many  medical  essays  on  this  subject  there  are  included  cases  of 
hypersecretion,  ulcer,  cancer,  of  reflex  pylorospasm  from  gall-bladder 
or  appendicular  diseases,  together  with  cases  of  hyperacidity  that  are 
due  to  gastroptosis  and  to  atony. 

While  all  these  pathological  conditions  show  hyperacidity  in  common, 
it  is  ob\'iously  an  error  to  group  them  together. 

The  only  proof  of  hyperacidity  is  the  analysis  of  the  gastric  contents. 
We  cannot  make  a  diagnosis  on  the  history  alone,  as  the  feeling  of  heart- 
burn va^y  accompany  subacidity  or  even  achylia,  while,  on  the  other 
hand,  we  meet  with  extreme  degrees  of  hyperacidity  which  give  rise  to 
no  gastric  discomfort  whatever.  In  spite  of  this  fact  patients  are  often 
said  to  be  suffering  from  hyperacidity,  without  proof  of  the  diagnosis 
^by  gastric  analysis.  We  have  no  means  of  determining  the  relative 
number  of  individuals  who  have  hyperacidity  without  symptoms,  and 
who,  therefore,  never  have  reason  to  ask  medical  advice  for  indigestion. 
It  is  probable  that  the  majority  of  patients  who  have  hyperacidity 
remain  unexamined  and  untreated. 


462  HYPERACIDITY 

Etiology. — Dietetic  Errors. — Dietetic  errors  are  generally  supposed  to 
be  the  most  prolific  cause  for  the  hyperacid  state.  Overexcitability 
of  the  gastric  glands  is  commonly  attributed  to  the  character  of  the 
food  that  is  eaten.  Overindulgence  in  condiments,  spices,  coffee, 
alcoholic  beverages,  sweets,  and  richly  prepared  food  are  cited  as  com- 
mon causes  for  the  ailment,  while  the  administration  of  certain  drugs, 
such  as  gentian,  capsicum,  nux  vomica,  and  the  essential  oils,  oil  of 
copaiba  and  sandalwood,  may  be  followed  by  attacks  of  the  disorder. 
Insufficient  mastication  and  the  bolting  of  food  in  large  masses,  food 
insufficiently  softened  by  cooking,  coarse  bread,  and  an  excess  of  hard 
vegetables  are  said  to  be  exciting  causes  for  the  complaint. 

Food  that  is  rich  in  nitrogenous  elements  is  known  to  produce  a 
more  acid  gastric  juice  than  is  a  diet  of  carbohydrates.  As  long  as  the 
supply  of  food  continues,  this  overacidity  continues  without  ill  affects, 
but  sliould  the  (Het  be  suddenly  restricted  from  any  cause,  the  excessive 
acidity  no  longer  neutralized  or  combined  with  food,  may  make  itself 
felt  by  heart-l)urn  and  other  symptoms  of  indigestion.  Fenwick  lays 
stress  on  this  point  and  claims  it  is  for  this  reason  that  so  many  bon 
^'ivants  suffer  from  acid  dyspepsia,  when  owing  to  an  attack  of  gout 
or  other  disease  they  are  obliged  to  confine  themselves  to  a  limited 
amount  of  food.  Sooner  or  later  the  stomach  adapts  itself  to  the 
requirements  of  a  new  diet.  Pawlow  found  that  whenever  in  feeding 
animals  the  kind  of  food  is  altered  and  the  new  diet  maintained  for  a 
length  of  time,  the  digesting  quality  of  the  juice  becomes  day  by  day 
more  and  more  adapted  to  the  new  dietetic  regime. 

When  we  come  to  consider  the  influence  which  food  has  ujion  gastric 
secretions,  in  the  light  of  recent  scientific  investigation  we  are  forced 
to  admit  that  it  has  been  very  greatly  overestimated.  It  has  been 
definitely  determined  by  Pawlow,  Hertz,  and  others  that  the  mucous 
membrane  of  the  stomach  is  totally  insensitive  to  sensory  stimula- 
tion and  that  the  direct  contact  of  the  interior  of  the  stomach  with 
irritating  food,  drugs,  acids,  foreign  bodies,  and  other  forms  of  stimula- 
tion does  not  in  the  least  influence  the  forms  of  gastric  juice.  "The 
mechanical  stimulation  of  the  stomach  wall  by  food  thus  causing 
further  the  secretory  work  of  th(^  glands  is  nothing  less  than  a  sad 
misconception."     (Pawlow.) 

Hyperacidity  is  more  commonly  seen  in  j)rivate  j)ractice  when  the 
food  is  well  cooked  and  wholesome  than  it  is  in  hospital  practice  in 
which  the  ])atients  habitually  indulge  in  dietetic  errors  of  the  grossest 
sort.  The  writer's  experience  on  this  point  coincides  with  that  of 
Fenwick.  Among  his  patients  with  hyperacidity  the  writer  cannot 
convince  himself  that  the  \^ari()us  dietetic  indiscretions  so  commonly 
causative  of  a  hyperacid  condition  are  any  more  frcciuent  or  flagrant 


ETIOIJHIY  OF  HYPERACIDITY  463 

than  can  be  observed  among  a  similar  number  of  patients  whose  diges- 
tions are  without  flaw  or  blemish.  It  is  well  upon  general  principles 
to  insist  upon  the  importance  of  simple  and  wholesome  food,  and  upon 
its  thorough  and  leisurely  mastication;  but  the  writer  believes  that  more 
harm  than  good  is  done  by  overdieting  the  patients  and  by  placing 
them  on  a  dietary  that  is  insufficient  and  unappetizing. 

Motor  Errors. — Motor  errors  both  small  and  great  are  probably  the 
commonest  form  for  hyperacidity,  and  the  more  carefully  we  study 
our  cases  the  greater  their  importance  grows  upon  us.  On  glancing 
at  the  table,  page  460,  of  the  various  causes  found  for  hyperacidity 
the  number  in  which  motor  inadequacy  was  a  prominent  factor  is 
surprisingly  great:  20.5  per  cent,  occurred  with  gastroptosis  and  atony, 
11  per  cent,  with  incomplicated  atony,  making  31.5  per  cent,  of  all 
cases  depending  upon  atonic  error.  Ulcer  was  present  in  19  per  cent. 
It  is  generally  accepted  that  in  ulcer  the  acidity  increasest  he  nearer 
is  the  ulcer  to  the  pylorus,  the  reason  being  that  in  ulcers  at  or  near 
the  orifice  a  certain  degree  of  stenosis  is  present,  either  structural  or 
spasmodic,  the  effect  of  which  is  regularly  to  cause  a  food  retention 
that  leads  to  hypersecretion  and  hyperacidity.  Saddle-back  ulcer 
of  the  lesser  curvature  may  also  interfere  with  gastric  motility  and  be 
followed  by  the  same  secretory  excess.  In  the  4  per  cent,  of  hyper- 
acidities accompanying  cancer  the  site  of  the  growth  was  pyloric  in 
every  instance,  while  in  the  hyperacidity  that  occurred  with  chronic  acid 
gastritis  evidences  of  slight  motor  error  were  found  in  all  the  cases. 

Diseases  of  the  gall-bladder  and  appendix  are  often  complicated  by 
hyperacidity  resulting  from  pylorospasm.  Certainly  motor  error  of 
such  a  nature  exists  in  a  large  proportion  of  cases  of  hyperacidity  accom- 
panying cholecystitis  or  chronic  appendicitis.  Of  two  hundred  cases 
of  cholecystitis  in  the  writer's  private  practice,  hyperacidity  was  present 
in  30  per  cent.  When,  therefore,  we  sum  up  the  cases  of  hyperacidity 
from  whatever  cause  it  may  arise,  motor  error  was  present  in  75  per 
cent,  of  the  writer's  cases.  This  is  a  higher  estimate  than  is  generally 
conceded. 

Graull^  found  hyperacidity  in  50  per  cent,  of  his  cases  of  atony, 
while  Kaufmann^  makes  a  somewhat  higher  estimate.  As  a  clinical 
fact,  whenever  food  exit  is  delayed,  hyperacidity  appears,  and  the  more 
careful  is  our  examination  of  patients  with  hyperacidity  the  larger  is 
the  number  of  gastric  atonies  and  motor  errors  of  insufficiency  that 
are  discovered.  A  further  description  of  the  relationship  between 
motor  errors  and  gastric  secretion  will  be  found  in  the  article  on 
Hypersecretion. 

^  Archiv  fiir  Verdauungskrank,  xiii,  627. 
2  Zeitschrift  klin.  Med.,  1905,  Ivii,  491. 


464  HYPERACIDITY 

Oswald  reports  that  among  his  cases  of  chlorosis  hyperacidity  was 
present  in  So  per  cent.,  while  Friedenwald  has  found  hyperacidity  in 
75  per  cent.  The  writer  cannot  place  his  figures  nearly  as  high  as  these, 
but  believes  that  hyiieracidity  does  not  occur  with  chlorosis  except 
in  those  chloranemic  patients  who  have  concomitant  gastric  atony 
and  in  whom  hyjjcracidity  exists  as  the  result  of  atony  rather  than  of 
the  anemia. 

Constipation. — The  correlation  between  constipation  and  hyperacidity 
has  not  been  })articularly  noticeable.  ^lany  patients  with  hyperacidity 
are  constipated,  but  the  writer  has  not  seen  as  yet  convincing  proof 
that  any  relief  to  the  constipation  is  attended  by  an  actual  reduction 
of  hydrochloric  acid  values,  although  the  patients  may  feel  subjectively 
relieved. 

Nervous  Causes. — The  influenc-e  of  the  nervous  system  upon  gastric 
digestion  is  generally  recognized  and  it  is  well  known  that  hyperacidity 
is  a  concomitant  symptom  of  neurasthenic  and  i)sychasthenic  states. 
This  disorder  is  extremely  ])rone  to  complicate  mental  disease,  hysteria 
and  ej)ilepsy.  \o\\  Xoorden  has  noted  its  frequency  in  melancholia. 
Psychic  influe^ices  frequently  induce  an  attack  in  nervous  individuals. 
Worry,  undue  excitement  or  outbursts  of  anger  are  often  followed  by 
the  symptoms  of  the  gastric  disorder.  There  is  no  doubt  that  mental 
strain  and  worry  are  imi)ortant  etiological  factors  in  the  production 
of  this  ailment.  It  is  not  uncommonly  observed  during  convalescence 
from  surgical  operations.  Any  cause  which  reduces  nervous  tone, 
such  as  poor  hygiene,  bad  ^'entilati()n,  or  physical  strains,  may  induce 
hyperacidity,  esi)ecially  if  the  jjatient  be  tempermciitally  susceptible 
to  such  influences.  Individuals  with  broad  costal  angles  are  not,  as 
a  rule,  thus  susceptible,  but  those  with  acute  costal  angles  and  the 
other  stigmas  of  the  enteroptotic  habit  are  especially  liable  to  the 
disorder,  and  it  is  in  these  enteroptotic  ])atieiits  that  the  production 
of  hyperacidity  after  iier\()us  strains  and  worries  seems  most  regular 
and  certain. 

The  writer  has  no  desire  whate\'er  to  minimize  the  importance  of 
ner\()us  strain  and  of  lowered  nerve  vitality  as  causes  for  tiu'  hyperacid 
state  of  the  stomach,  but  he  cannot  believe  that  these  neurasthenic 
and  psychic  influences  actually  j)roduce  an  uncontrolled  excitability 
of  the  secretory  nerx'c  sii])ply  of  the  stomach  that  results  in  the  over- 
j)roduction  of  gastric  juice.  It  would  seem  more  ])robable  that  these 
conditions  of  h)wered  nerve  tone  are  accompanied  as  part  and  parcel 
of  tlie  symptom-complex  by  atony  of  the  gastric  wall,  and  that  to  the 
atony  the  hyperacidity  is  due. 

Symptoms.  In  discussing  the  symj)tomatology  of  hyperacidity  it 
is  ini|)ortant   to  separate  the  cases  of  s(>c()ndary   liyperaciditN'  due  to 


SYMPTOMS  OF  HYPERACIDITY  465 

demonstrable  organic  disease  of  the  alimentary  tract  from  those  of  the 
primary  or  functional  form,  for  the  reason  that  in  the  secondary  group 
the  symptoms  of  hyperchlorhydria  are  so  intermixed  with  those  of  the 
original  causative  malady  that  the  resulting  symptom-complex  is  often 
exceedingly  confusing.  The  following  description  of  symptoms  in- 
cludes therefore  only  those  of  the  primary  form.  Hyperacidity  due 
to  demonstrable  organic  disease  is  discussed  under  the  heading  of  the 
disease  to  which  it  is  secondary.  Much  of  the  confusion  which  results 
from  the  reading  of  certain  medical  essays  on  this  subject  might  have 
been  a\'erted  had  there  been  made  this  division  of  the  subject  into 
these  two  groups. 

Symptoms  of  Primary  or  Functional  Acidity. — The  majority  of  patients 
give  no  definite  symptoms,  as  the  disease  runs  a  latent  course  and  is 
discovered  only  by  a  routine  examination  of  the  stomach  contents. 
In  these  cases  we  have  no  means  of  determining  whether  the  process  is 
a  temporary  one,  present  only  at  the  time  of  the  examination,  or  one 
of  longer  duration.  In  the  patients  who  present  symptoms  of  indiges- 
tion that  may  be  attributed  to  the  excessive  acidity,  only  a  small  number 
give  symptoms  that  may  be  referred  to  the  stomach  itself.  By  far 
the  greater  number  complain  of  intestinal  indigestion  characterized 
by  abdominal  discomfort  and  distress,  by  irregularities  in  the  action 
of  the  bowels,  or  by  symptoms  of  intestinal  toxemia,  such  as  headache, 
mental  depression,  and  the  symptom-complex  ordinarily  described  as 
biliousness.  The  various  symptoms,  gastric,  intestinal,  and  toxemia, 
will  now  be  described  in  more  detail. 

Gastric  Symptoms. — Heart-burn  is  a  symptom  which  is  generally 
indicative  of  hyperacidity.  It  is,  as  its  name  signifies,  a  burning  feeling 
referred  to  the  epigastric,  substernal,  or  cardiac  areas,  or  to  the  lower 
part  of  the  neck  or  throat,  usually  radiating  upward,  occasionally  to 
the  back,  but  never  downward.  Properly  speaking  it  is  not  a  pain, 
but  a  feeling  of  distress.  This  distinction  is  an  important  one.  The 
burning  distress  comes  in  simple  hyperacidity  only  during  the  height  of 
digestion  and  should  subside  as  the  stomach  empties  itself.  Heart- 
burn appearing  later  than  three  or  four  hours  after  eating  suggests 
hypersecretion,  and  if  complaint  is  made  of  burning  distress  during 
the  latter  part  of  the  night  or  early  morning,  hypersecretion  with  motor 
error  of  the  stomach,  probably  from  pyloric  narrowing,  may  be  inferred. 
The  distress  is  regularly  relieved  by  eating,  by  drinking  alkaline  solu- 
tions, or  emptying  the  stomach ;  but  it  is  rare  for  the  heart-burn  to  be 
sufficiently  annoying  to  cause  the  patient  to  induce  ^•omiting  for  its 
relief.    If  such  be  the  case  ulcer  is  more  probable. 

Heart-burn  has  generally  been  considered  due  to  the  irritation  of 
the  gastric  mucosa  by  overacid  stomach  contents,  but  as  it  has  been 
30 


466  HYPERACIDITY 

proved  that  the  gastric  and  esophageal  mucosa  is  absolutely  insensitive 
to  hydrochloric  acid  even  in  far  greater  concentration  than  is  ever 
found  in  health  or  in  disease,  it  is  evident  that  at  present  its  causation 
is  obscure.  Furthermore,  the  intensity  of  the  heart-burn  gives  no 
correct  inference  whatever  as  to  the  degree  of  acidity  that  exists. 
Total  acidities  of  90  and  over  may  not  produce  the  least  amount  of 
discomfort,  while,  on  the  other  hand,  very  considerable  distress  may  be 
present  with  normal  or  diminished  acidity,  or  even  with  achylia. 

Pyrosis,  or  the  rising  of  acid  fluid  in  the  mouth,  is  an  infrequent 
complaint  and,  properly  speaking,  should  not  occur  with  hyperacidity 
that  is  not  complicated  by  hypersecretion.  Patients  with  varied 
gastric  disorders  often  complain  of  sour  food  coming  up  into  the  mouth 
during  digestion  as  acid  as  lemon  juice  or  vinegar,  and  are  led  to 
regard  their  digestion  as  abnormally  acid,  not  knowing  that  the  gastric 
digestion  is  normally  acid  and  that  after  all  they  are  suffering  only 
from  regurgitation  of  food  in  a  natural  state  of  digestion  akin  to  the 
"spilling"  of  babies  after  the  taking  of  food.  Unless  reassured  on  this 
point  they  may  do  themselves  harm  by  unnecessary  medication  and 
restriction  of  diet. 

The  raising  of  acid  fluid  unmixed  with  solids  indicates  regularly 
a  hypersecretion,  especially  when  it  is  most  marked  toward  the  latter 
part  of  the  digestion  when  the  food  is  leaving  the  stomach.  Acid- 
rising  in  the  fasting  state  does  not  occur  with  simple  hyperacidity. 
Flatulence  accompanies  many  of  the  cases  and  is  almost  always  due 
to  swallowed  air.  The  amount  of  gas  or  wind  is  usually  proportionate 
to  the  degree  of  gastric  atony  that  is  present.  In  the  writer's  experience 
hyperacidity  without  atony  is  not  accompanied  by  gas,  but  in  hyper- 
acidity with  atony,  flatulency  is  regularly  present. 

A  sense  of  fulness,  uneasiness,  or  burning  in  the  epigastrium  which 
may  culminate  in  an  expulsion  of  wind  from  the  stomach  is  common 
in  hyperacidity.  These  symptoms  are  due  to  the  fact  that  an  excess  of 
hydrochloric  acid  increases  the  peristaltic  power  of  the  stomach  and  at 
the  same  time  induces  spasm  of  both  the  pyloric  and  cardiac  sphincters, 
the  combined  result  of  which  is  to  raise  the  intragastric  pressure  and 
cause  discomfort.  This  theory,  however,  does  not  explain  why  one 
individual  with  marked  and  persistent  hyperacidity  will  not  present 
any  abdominal  sensations,  while  severe  epigastric  distress  and  heart- 
burn may  occur  in  those  whose  gastric  analyses  show  a  normal  or  even 
(liniiiiished  acidity.  It  has  been,  therefore,  supi)osed  that  the  suscep- 
tibility of  the  stomach  to  free  hydrochloric  acid  varies  considerably 
in  difi'erent  individuals,  and  that  many  people  are  able  to  bear  with 
impunity  degrees  of  acidity  that  would  j)roduce  severe  suffering  in 
others.  Experimeiitiil  proof  of  the  correctness  of  this  theory  is, 
however,  larking. 


SYMPTOMS  OF  HYPERACIDITY  467 

Alth()iio;h  a  sudden  increase  of  intragastric  pressure  may  produce 
discomfort  and  distress,  actual  pain  is  exceedingly  rare,  and  its  occur- 
rence, especially  if  recurring  at  stated  intervals,  should  regularly  suggest 
the  strong  probability  of  an  organic  cause,  such  as  ulcer,  gall-bladder 
disease,  or  chronic  appendicitis.  The  majority  of  writers  speak  of  pain, 
often  to  the  point  of  agony,  necessitating  the  use  of  narcotics,  as  a 
regular  accompaniment  of  hyperacidity,  and  even  the  most  conserva- 
tive diagnosticians  assert  that  simple  hyperacidity  without  demon- 
strable organic  disease  in  the  stomach,  such  as  ulcer  or  cancer,  may  at 
times  produce  painful  sensations.  Fenwick  claims  that  in  every  chronic 
case  of  hyperchlorhydria  the  acidity  gradually  subsides  until  subacidity 
is  attained,  while  at  the  same  time  painful  sensations  are  increased 
rather  than  diminished,  and  that  the  administration  of  bicarbonate 
of  soda  aggravates  rather  than  relieves  the  suffering.  He  adds  that  in 
every  case  of  this  nature  in  which  he  has  seen  the  stomach  opened  for 
exploration,  the  mucous  membrane  w^as  purple,  swollen,  and  covered 
with  superficial  hemorrhages  or  erosions,  while  microscopical  exami- 
nation showed  interstitial  gastritis  of  the  kind  that  is  produced  by 
chemical  irritants,  and  he  believes  that  this  severe  diffuse  gastritis 
renders  the  stomach  intolerant  of  any  degree  of  acidity,  of  alkalies 
or  even  of  food  itself. 

The  author  has  had  no  experience  with  cases  of  this  clinical  type 
and  doubts  if  such  a  course  is  observed  apart  from  those  cases  in  which 
painful  acidity  is  the  clinical  evidence  of  organic  demonstrable  disease. 
Hyperacidity  changing  into  subacidity  or  anacidity  associated  with 
epigastric  pain  which  becomes  progressively  more  severe  and  continuous 
and  unrelieved  by  alkalies,  has  in  the  writer's  experience  turned  out  to 
be  chronic  gastric  ulcer  undergoing  malignancy.  The  writer  is  extremely 
skeptical  as  to  the  occurrence  of  actual  pain  in  primary  or  functional 
hyperacidity.  In  his  experience  patients  with  hyperacidity  in  whom 
organic  disease  can  be  excluded,  rarely,  if  ever,  complain  of  any  painful 
sensations  or  even  discomfort  during  the  digesting  period. 

Negative  Gastric  Symptoms. — The  negative  gastric  symptoms  of 
hyperacidity  are  important. 

1.  Nausea  is  not  a  symptom  of  hyperacidity  and  is  never  observed 
in  uncomplicated  cases. 

2.  Vomiting  is  seldom  if  ever  spontaneous,  but  it  may  be  induced 
for  the  relief  of  gas  and  epigastric  distress.  There  are,  however, 
many  people  who  are  intolerant  of  any  degree  of  gastric  discomfort, 
and  who  have  learned  early  in  their  career  the  trick  of  emptying  their 
stomach  on  slight  provocation.  This  voluntary  and  often  totally 
unnecessary  emesis  may  be  quite  misleading  to  the  physician  unless 
by  a  careful  inc|uiry  the  emesis  habit  is  discovered  and  the  fact  elicited 


408  HYPERACIDITY 

that  the  symptoms  for  which  tlie  emptying  of  the  stomach  was  suggested 
were  exceedingly  shght.  Such  vomiting  possesses  \-ery  Httle  clinical 
significance  unless  the  suffering  for  the  relief  of  which  it  is  induced  is 
sufficient  to  warrant  it. 

3.  The  appetite  is  either  unchanged  or  increased,  rarely  diminished. 

4.  ^'olunta^y  reduction  of  food  by  the  dread  of  subsequent  pain 
and  distress  is  not  noticed  in  simple  hyperacidity,  but  is  far  more 
significant  of  ulcer  or  of  extreme  degrees  of  atony,  the  former  giving 
rise  to  pain  which  the  patient  desires  to  avoid,  the  latter  to  distress, 
heaviness,  and  gas  within  the  stomach. 

0.  Hemorrhages,  either  visible  or  occult,  do  not  occur  in  uncompli- 
cated hyperacidit}'.  When  present  ulcer  or  erosions  should  be  suspected. 
Small  hemorrhages  with  hyperacidity  in  those  of  adult  years  should 
suggest  cancer. 

(').  The  general  condition  remains  unchanged.  The  strength  and 
body  nutrition  are  unimpaired. 

Intestinal  Symptoms. — The  bowels  may  remain  normal  throughout 
the  course  of  the  ailment,  although  the  majority  of  patients  are  more 
or  less  constipated.  In  chronic  cases  attacks  of  diarrhea  may  super\ene 
from  time  to  time  accompanied  b}'  intestinal  discomfort  and  flatulence 
and  are  often  treated  as  due  to  chronic  colitis  without  any  consideration 
being  paid  to  the  primal  cause  for  the  complaint. 

Intestinal  indigestion  may  produce  symptoms  in  many  ways.  Ab- 
dominal distention  and  discomfort  are  the  most  common  symptoms 
present  and  are  usually  most  prominent  two  or  three  hours  after  meals 
when  intestinal  peritalsis  begins.  The  distention  is  generally  diffused 
and  symmetrical,  the  distress  is  most  marked  in  the  middle  and  lower 
abdominal  zones.  These  intestinal  symptoms  may  be  the  only  evidence 
of  hyperacidity  which  the  j^atient  presents,  and  the  origin  of  the  malady 
in  the  stomach  is  often  overlooked.  It  cannot  be  too  strongly  insisted 
upon  that  in  every  case  of  so-called  intestinal  indigestion,  an  examina- 
tion of  the  stomach  contents  should  be  made.  In  many  patients  with 
hyperacidity  there  is  an  interference  with  the  intestinal  digestion  of 
a  nature  that  we  are  at  present  unable  to  determine,  but  which  is 
{'haracterijced  l)y  s\mptoms  of  a  mild  toxic  nature,  which  for  want  of 
a  l)ettcr  term  we  designate  as  auto-intoxication. 

Headache  is  the  ])rincipal  symptom  and  may  occur  in  one  of  two 
forms : 

1.  '^riicrc  may  recur  da\'  after  day  a  dull  heavy  ache  without  any 
characteristic  locahzation,  generally  more  marked  in  the  morning 
and  passing  away  as  the  day  ])rogresses.  As  a  rule  the  ])atient  feels 
heavy,  d()p\-,  and  disinclined  to  either  mental  or  piiysical  exertion. 
The  bowels  arc  usually  C()iisti])atc(l,  the  tongue  coated,  and  the  breath 


DIAdNOSIS  OF  HYPERAC/D/TY  4f)0 

oft'ensive,  the  c()m])l('xi()ii  often  taking  on  a  sallow  hue.  These  patients 
eall  themselves  "hihous"  and  resort  to  ne\er-en(linfi;  medieation. 

2.  There  may  be  a  dull,  horing  pahi  startnig  in  the  eyeball  over  one 
or  the  other  side  and  gradually  beeoming  hemicranial  in  type.  The 
headache  may  be  more  generalized  toward  the  close  of  the  attack. 
In  severe  instances  of  this  type  the  headache  may  be  sudden,  sharp, 
and  generalized,  and  accompanied  by  photophobia  and  intolerance  to 
noise.  Nausea  and  vomiting  may  occur,  but  the  vomiting  of  large 
quantities  of  acid  fluid  as  sometimes  described  does  not  appear  in 
these  cases. 

Diagnosis. — Physical  Examination. — Physical  examination  is  usually 
negative.  There  are  no  characteristic  signs.  There  may  be  a  slight 
tenderness  in  the  epigastrium  during  the  acme  of  the  distress,  but 
this  is  negligible  from  a  diagnostic  standpoint.  Xo  examination  is 
complete  that  does  not  thoroughly  investigate  the  motor  power  of 
the  stomach  and  the  condition  of  the  gall-bladder  and  appendix.  The 
physically  signs  of  ulcer  and  cancer  must  be  repeatedly  searched  for. 

Gastric  Analysis. — Examination  of  the  gastric  contents  is  absolutely 
necessary  for  the  diagnosis  of  hyperacidity,  as  it  is  impossible  to  diag- 
nosticate the  malady  by  subjective  symptoms  alone.  Examination 
should  be  made  both  in  the  fasting  and  the  digesting  state. 

Fasting  Stomach. — The  fasting  stomach  should  be  empty  of  both  acid 
fluid  and  food  remains.  Quantities  of  fluid  under  30  c.c.  are  negligible 
but  exceeding  this  amount  indicate  that  some  organic  complication 
is  present.  Hyperacidity  never  passes  into  food  stasis  unless  due  to 
organic  or  spasmodic  closure  of  the  pylorus. 

Test  Breakfast. — The  gastric  contents  aspirated  one  hour  after  the 
taking  of  the  ordinary  Ewald  test  breakfast  usually  show  to  the  naked 
eye  no  departure  whatever  from  the  normal.  The  breadstuff s  are  finely 
chymified  and  homogeneous.  There  is  usually  no  increase  in  the  amount 
of  gastric  mucus.  Upon  settling,  the  contents  separate  into  tw^o  layers, 
the  supernatant  layer  not  exceeding  the  depth  of  that  of  the  layer 
of  solids  beneath.  This  limitation  in  the  amount  of  free  fluid  differen- 
tiates between  hyperacidity  and  alimentary  hypersecretion — a  totally 
different  disease. 

The  total  acidity  usually  ranges  from  65  to  90,  rarely  reaching  this 
latter  point.  Acidities  over  90  are  almost  invariably  associated  with 
closure  lesions,  spasmodic  or  organic,  of  the  pylorus,  and  in  these  cases 
hypersecretion  is  usually  encountered  as  well.  Free  and  combined 
hydrochloric  acid  are  present,  about  20  points  of  the  total  acidity  being 
taken  by  the  combined  acid,  S  points  by  acid  salts,  the  balance  by 
free  acid.  Lactic  and  other  organic  acids  are  absent.  Reactions  for 
peptones  show  normal  or  excessive  proteid  digestion.    There  is  a  natural 


470  HYPERACIDITY 

interference  with  the  digestion  of  starches,  the  gastric  contents  fail  to 
exhibit  the  usual  reactions  for  maltose  while  those  for  erythrodextrin 
and  amidulin  are  well-marked.  Sarcinjie  are  not  present  except  in  the 
cases  complicated  by  stenosis  of  the  pylorus  and  food  retention. 

Stool  examinations  in  hyperacidity  with  intestinal  or  auto-intoxica- 
tion symptoms  seldom  afford  much  if  any  clue  to  diagnosis.  There 
may  be  small  clumps  of  undigested  starch  granules,  often  bile-tinged, 
enclosed  in  a  mucous  capsule,  indicating  a  catarrhal  lesion  high  up  in 
the  small  intestine,  which  is  often  the  result  of  excessive  gastric  acidity. 
Fermentation  of  the  stools  according  to  the  method  recommended  by 
Schmidt  and  Strassberger  has  to  the  writer  been  totally  inadequate 
for  diagnostic  purposes.  The  presence  of  mucus  in  the  stools,  either 
enteric  or  colonic  in  origin,  is  of  little  diagnostic  importance.  With 
intestinal  toxemia  indican  is  usually  present  in  increased  amount  in 
the  urine,  although  indicanuria  may  be  present  without  intestinal  or 
toxic  symptoms,  while,  on  the  other  hand,  these  complaints  may  occur 
to  a  distressing  degree  without  indicanuria  beyond  normal  limitations. 
Too  much  stress,  therefore,  should  not  be  laid  upon  this  test. 

Larval  Hyperacidity. — ^To  explain  the  cases  in  which  symptoms  of 
hyperacidity  are  present,  but  in  which  the  test  breakfast  shows  normal 
or  diminished  acidity,  Strauss  suggests  the  following  theory :  The  intro- 
duction of  food  into  the  stomach  is  followed  by  a  pouring  out  of  gastric 
juice  of  a  definite  acidity  that  is  constant  in  all  cases  and  is  always 
stronger  in  concentration  than  is  necessary  for  the  digestion  of  the  food. 
To  bring  this  hyperacid  fluid  down  to  the  desired  dilution,  there  is 
poured  into  the  stomach  a  neutral  fluid  which  is  called  "thinning 
fluid."  The  final  gastric  juice  is  thus  an  admixture  of  the  first  overacid 
secretion  and  the  second  thinning  secretion.  The  test  breakfast  at 
the  expiration  of  one-half  hour  shows  an  extreme  degree  of  hyper- 
acidity, while  examination  at  the  expiration  of  an  hour  shows  the 
acidity  to  be  reduced  to  normal  or  even  below  the  normal  limits.  To 
these  cases  he  gives  the  name  "Larval  Hyperacidity." 

The  following  diagram  from  an  article  by  FriedenwahP  shows  clearly 
what  is  supposed  to  occur  in  these  cases.  This  writer  is  a  strong  advo- 
cate of  Strauss'  theory  of  larval  hyperacidity-,  and  in  the  article  just 
cited  he  gives  the  record  of  0  cases  he  himself  has  investigated.  It  is 
quite  evident,  however,  that  Friedenwald  was  not  dealing  with  simple 
hyperacidity  but  with  alimentary  hypersecretion,  for  in  his  cases  the 
amount  of  test  l)reakfast  abstracted  was  excessive,  ranging  from  215 
to  365  c.c,  the  bulk  being  composed  of  fluid  so  copious  that  the  depth 
of  the  supernatant  layer  was  four  times  that  of  the  underlying  layer 
of  digested  breadstufts. 

'  Amer.  Jour.  Med.  Sci.,  August,  1911,  p    160. 


DIAGNOSIS  OF  HYPERACIDITY 


471 


Differential  Diagnosis. — No  diagnosis  of  hyixTacidity  or  hyperchlor- 
hydria  should  ever  be  made  unless  all  organic  conditions  are  positively 


m 

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Fig.  97 
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90 


30  45  60  ; 

MINUTES 
Curve  of  acidity  in  a  normal  case  of  hyperacidity  after  an  Ewald  test  breakfast.    Solid  line  =  total 
acidity;  dotted  line  =  HCl;  X  =  free  hydrochloric  acid.     (Friedenwald.) 


60 

50 

^40 

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Fig.  98 
45  60 


75 


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30  45  00 

MINUTES 


90 


Curve  of  acidity  in  a  case  of  larval  hyperacidity  after  an  Ewald  test  breakfast.    Solid  line  =  total 
acidity;  dotted  line  =  HCl;  X  =  free  hydrochloric  acid.     (Friedenwald.) 


excluded.  If  an  exclusion  of  these  organic  causes  for  the  ailment 
cannot  be  made,  the  diagnosis  should  be  made  tentatively  with  a  view 
of  arriving  at  a  more  definite  conclusion  as  the  case  develops. 


472  HYPERACIDITY 

Diagnosis  from  Hypersecretion.  —  (o)  Continuous  hypersecretion 
should  be  suspected  whenever  symptoms  of  hyperacidity  appear  at 
a  time  when  the  stomach  should  normally  be  empty,  and  the  diagnosis 
may  be  made  with  absolute  certainty  by  the  constant  presence  of  over 
30  c.c.  of  acid  fluid  giving  reactions  for  free  hydrochloric  acid,  in  the 
fasting  state. 

(6)  Alimentary  hypersecretion  may  cause  distress  during  the  digest- 
ing period,  as  in  simple  hyperacidity;  but  the  diagnosis  can  be  made 
without  difficulty  by  the  test  breakfast,  which  is  excessive  in  quantity 
and  of  fluid  consistency,  separating  into  two  layers  on  standing,  the 
supernatant  fluid  being  more  than  twice  the  depth  of  the  sedimentary 
layer. 

Diagnosis  from  Ulcer. — The  diagnosis  between  simple  hyperacidity 
and  ulcer  is  often  difficult.  The  problem  may  be  simplified  by  the 
following  considerations : 

(a)  Hyperacidity  that  is  accompanied  by  pain  is  not  functional, 
but  is  due  regularly  to  an  organic  cause,  which  may  be  ulcer,  cancer, 
gall-bladder,  or  appendix.  The  diagnosis  of  ulcer  is  then  worked  out 
by  exclusion,  although  it  often  happens  that  a  positive  diagnosis  can 
only  be  made  by  exploration. 

(6)  When  hyperacidity  is  accompanied  only  by  heart-burn  or  dis- 
tress the  differential  diagnosis  is  more  difficult.  The  more  severe  the 
discomfort  the  greater  the  possibility  of  there  being  an  organic  cause 
for  the  ailment. 

(c)  Hyperacidity  symptoms  occurring  toward  the  close  of  digestion 
or  when  the  stomach  should  be  empty  are  not  of  functional  origin, 
but  are  more  usually  due  to  ulcer  or  to  appendicitis  than  to  any 
other  organic  cause. 

{d)  Symptoms  of  hyperacidity  that  are  aggravated  by  errors  in  diet 
may  be  considered  as  presumable  evidence  of  ulcer.  In  ulcer  the 
symptoms  are  usually  relieved  by  a  few  days  of  milk  diet,  while  in 
hyperacidity  this  cessation  of  symptoms  is  but  rarely  observed. 

{e)  Symptoms  of  hyperacidity  running  a  prolonged  course  unrelie\ed 
to  any  great  extent  by  treatment  are  in  all  probability  due  to  ulcer, 
provided  that  chronic  appendicitis  and  lesions  of  the  gall-bladder  can 
be  excluded.  Paterson^  operated  on  50  cases  of  persistent  hyper- 
chlorhydria,  and  in  every  instance  found  that  there  was  an  organic 
lesion  either  in  the  stomach  or  duodenum,  gall-bladder  or  appendix. 

(/)  Occult  blood  in  the  gastric  contents  or  in  the  stools  is  rather 
against  functional  hyperacidity,  but  too  much  reliance  must  not  be 
placed  upon  these  tests,  as  hyperacidity  may  be  complicated  by  pore- 

'  Quoted  by  Moynihan,  Liincet,  .January  0,  1912. 


DIAGNOSIS  OF  HYPERACIDITY  473 

like  erosions  from  which  tlie  bleeding  takes  place  withont  any  gross 
organic  lesion  being  found. 

Diagnosis  from  Cancer. — Cancer  at  its  onset  may  be  mistaken  for 
hyperacidity,  especially  if  there  is  carcinomatous  degeneration  of  a 
chronic  ulcer  at  or  near  the  pylorus,  or  early  cancer  of  the  gastric  wall 
with  greatly  impaired  motility.  Hyperacidity  with  cancer  is  far  more 
frequent  than  is  ordinarily  supposed.  Favoring  cancer  are  the  anorexia, 
advancing  chloranemia  and  weakness  in  a  patient  of  middle  age  who 
has  ordinarily  been  able  to  eat  wdth  relish  and  without  discomfort, 
occult  hemorrhages,  increasing  food-stasis,  and  in  the  later  stages  of 
the  disease  the  physical  evidences  of  tumor  and  possibly  of  metas- 
tases. 

Diagnosis  from  Gall-bladder  Infections  and  Gallsiones. — Gall-bladder 
infections  and  gallstones  may  produce  symptoms  of  hyperacidity  in 
one  of  two  ways: 

(fl)  There  may  be  a  reflex  hyperesthesia  of  the  stomach.  The  patient 
will  complain  of  heat  and  burning  in  the  substernal  or  epigastric  region, 
half  to  one  hour  after  eating  and  will  say  that  his  stomach  is  "  scalded 
with  too  much  acid."  In  these  cases  there  is  an  intolerance  for  hot 
drinks  that  is  quite  characteristic.  Soup,  tea,  and  cofi^ee  must  be  cooled 
before  they  can  be  swallowed  without  producing  a  burning  pain  in  the 
esophagus.  Immediate  relief  follows  a  few  sips  of  cold  water,  or  the 
taking  of  soda.  That  these  symptoms  are  not  due  to  actual  hyperacidity 
is  shown  by  the  fact  that  in  many  instances  the  gastric  contents  with- 
drawn at  the  time  of  the  greatest  distress  may  show  normal  or  even 
subnormal  acidity.  It  is  difficult  to  explain  these  cases  after  the  experi- 
mental work  of  Pawlow,  Hertz,  and  others,  w^hich  seems  to  prove  the 
absence  of  all  painful  sensations  in  the  esophageal  and  gastric  mucosa, 
when  bathed  in  even  stronger  solutions  of  hydrochloric  acid  than  are 
known  in  health  or  disease.  The  fact  remains,  however,  that  such  a 
distressing  heart-burn  and  an  intolerance  for  hot  fluids  clinically  does 
exist  and  many  continue  with  or  without  physical  signs  of  gall-bladder 
diseases  for  months,  ceasing  only  when  a  gallstone  is  passed  or  after 
the  gall-bladder  has  been  removed  or  drained  from  obvious  outbreak 
of  gall-bladder  infection. 

(6)  Gall-bladder  infections  or  gallstones  may  produce  an  actual 
and  demonstrable  hyperacidity  by  inducing  reflex  pylorospasm  with 
delayed  or  impaired  food  exit.  The  gall-bladder  lesions  may  be  clinically 
obscure  or  even  latent.  The  importance  of  repeated  examinations 
of  the  gall-bladder  cannot  be  too  strongly  emphasized  in  all  derange- 
ments of  gastric  secretion  whether  of  hyperacidity  or  anacidity.  A 
carefull}^  taken  history  will  usually  show  that  there  have  been  localized 
attacks  of  discomfort  over  the  gall-bladder.     Furthermore,  the  symp- 


474  HYPERACIDITY 

toms  show  an  irregularity  in  the  time  at  which  they  appear  after  the 
taking  of  meals,  which  is  not  the  rule  with  hypersecretion  or  ulcer. 

Diagnosis  from  Diseases  of  the  Appendix. — Diseases  of  the  appendix, 
especially  the  chronic  form  of  obliterative  inflammation,  may  produce 
reflex  pylorospasm  and  hyperacidity,  and  are  usually  though  not 
invariably  accompanied  by  epigastric  pain.  In  some  instances  the 
pylorospasm  is  increased  by  the  formation  of  minute  erosions  and  is 
occasionally  complicated  by  hematemesis.  In  these  cases  there  is  apt 
to  be  considerable  tenderness  over  the  pyloric  portion  of  the  stomach. 
It  is  important  to  remember  that  the  local  signs  of  chronic  appendicitis 
may  be  trifling  or  even  entirely  absent,  nor  may  there  be  in  the  history 
any  evidence  indicating  previous  attacks  of  inflammation.  Iti  every 
case  of  prolonged  or  painful  hyperacidity  chronic  appendicitis  must  he 
considered  a  possible  cause,  even  in  the  absence  of  definite  physical  signs. 

Diagnosis  from  Hyperacid  Gastritis. — The  symptoms  of  hyperacid 
gastritis,  as  a  rule,  are  more  influenced  by  improper  diet  and  abuse  of 
alcohol  than  is  the  case  with  hyperacidity,  although  this  rule  is  a  poor 
one  to  rely  upon,  as  hyperacidity  that  is  due  to  ulcer  may  be  subject 
to  fluctuations  depending  entirely  upon  dietetic  errors.  Much  valuable 
information  is  given  by  gastric  analysis.  In  gastritis  the  fasting  stomach 
contains  usually,  but  not  invariably,  a  definite  quantity  of  gastric 
mucus,  usually  of  an  acid  reaction,  and  often  containing  starchy  food 
remains  that  may  be  detected  by  the  microscope  but  not  by  the  naked 
eye.  The  test  breakfast  is  scanty,  the  food  is  intimately  admixed  with 
tenacious  gastric  mucus  and  does  not  readily  separate  into  the  fluid 
and  solid  layers  as  does  the  test  breakfast  of  hyperacidity. 

Lavage  in  gastritis  brings  glairy  mucus,  while  this  is  not  the  case 
with  hyperacidity.  It  should  be  remembered,  however,  that  chronic 
gastritis  may  coexist  with  hyperchlorhydria  due  to  other  causes,  and  it 
is  safe  to  say  that  a  larger  number  of  the  cases  of  so-called  chronic  acid 
gastritis  are  really  chronic  ulcer  of  the  stomach. 

The  following  practical  rules  for  diagnosis  are  suggested. 

1.  Do  not  make  a  diagnosis  of  hyperacidity  until  all  organic  lesions 
are  excluded,  and  even  then  be  prepared,  with  open  and  unbiased  mind, 
to  change  the  diagnosis  to  one  that  is  more  definite  and  distinctive 
should  other  symptoms  and  physical  signs  appear. 

2.  Do  not  make  the  diagnosis  of  hyperacidity  without  examinations 
of  the  fasting  stomach  by  a  tube.  The  presence  of  acid  fluid  or  of  food 
remains,  or  of  any  considerable  amount  of  acid  mucus  should  exclude 
the  diagnosis'. 

?y.  Do  not  make  the  diagnosis  of  hyperacidity  simply  because  the 
])atierit  is  nervous  or  neurotically  hypersensitive. 

4.  Do  not  make  the  diagnosis  of  hyperacidity  should  the  previous 
clinical  history  suggest  attacks  that  may  point  to  appendicular  or  gall- 


TREATMENT  OF  HYPERACIDITY  475 

bladder  disease,  or  sliouM  the  results  (^f   the  physical  examination  be 
such  that  these  lesions  are  {)robable. 

0.  Do  not  make  the  diagnosis  of  hyperacidity  in  cases  accompanied 
by  epigastric  pain  whether  dependent  or  not  upon  the  taking  of  food. 
Especially  should  this  diagnosis  be  avoided  if  the  pains  occur  at  a 
regular  period  after  eating. 

6.  Do  not  make  the  diagnosis  of  hyperacidity  if  hemorrhages  from 
the  stomach  or  intestines  are  present,  either  visible  or  occult.  The 
examination  of  the  stools  for  occult  blood  is  a  routine  examination  in 
these  cases  that  should  never  be  neglected. 

7.  Do  not  make  the  diagnosis  of  hyperacidity  in  cases  accompanied 
by  repeated  vomiting,  especially  if  the  vomiting  be  of  the  abundant 
acid  fluid  indicative  of  hypersecretion. 

8.  Do  not  make  the  diagnosis  of  hyperacidity  when  the  symptoms 
occur  at  a  time  when  the  stomach  should  be  empty. 

9.  Do  not  make  the  diagnosis  of  hyperacidity  in  the  event  of  the 
test  breakfast  settling  into  layers,  the  supernatant  fluid  being  more 
than  twice  the  depth  of  the  sedimentary  layer.  These  are  the  cases  of 
alimentary  hypersecretion  with  which  hyperacidity  pure  and  simple 
has  nothing  to  do. 

10.  Do  not  make  the  diagnosis  of  hyperacidity  in  cases  attended  with 
anorexia,  with  nausea,  with  advancing  anemia,  and  with  progressive 
loss  of  flesh,  especially  if  the  patient  be  of  adult  years,  with  or  without 
a  previously  good  digestion. 

11.  Do  not  make  the  diagnosis  of  hyperacidity  without  mental 
reservation  in  those  over  forty-five  who  complain  of  this  disorder  for 
the  first  time. 

12.  Do  not  make  the  diagnosis  of  hyperacidity  in  any  case,  no  matter 
what  the  symptoms  may  be,  without  corroboration  by  gastric  anah'sis. 

Course. — The  course  of  the  disease  depends  upon  the  nature  of  the 
exciting  cause,  so  that  we  have  all  variations  from  a  discomfort  that  is 
ephemeral  and  temporary  to  a  harassing  ailment  extending  continuously 
or  intermittently  for  months  or  years.  Continuous  hypersecretion 
almost  invariably  is  due  to  some  organic  lesion,  usually  ulcer  or  chronic 
appendicitis. 

Prognosis. — The  prognosis  of  hyperacidity  is  good  for  life  but 
uncertain  as  to  duration.  Being  after  all  only  a  symptom  that  arises 
from  varied  causes,  the  prognosis  depends  entirely  upon  the  tractability 
of  the  underlying  disease. 

Treatment. — Hyperacidity  is  only  a  symptom,  and  its  treatment, 
therefore,  is  that  of  the  condition  to  which  it  is  due.  The  diagnosis 
after  all  is  of  the  first  importance.  Hyperacidity  due  to  ulcer,  gastric 
or  duodenal,  to  lesions  of  the  gall-bladder  or  appendix,  may  be  tempor- 
arily relieved  by  alkalies,  but  the  real  treatment  is  naturally  that  of 


4:7(]  HYPERACIDITY 

the  ulcer,  gall-bladder  or  appendicular  disease.  It  is  unfortunate  that 
so  much  valuable  time  is  wasted,  physical  suffering  prolonged  and  the 
lives  of  the  patients  kept  in  jeopardy  by  i)erj)etual  tinkering  at  the 
symptoms  by  lavage  and  alkalies  when  a  more  radical  treatment  is 
necessary.  Hyperacidity  accompanying  atony  rarely  gives  rise  to  any 
symptoms  that  call  for  relief,  nor  would  it  be  of  much  use  to  treat 
such  a  case  on  purely  symptomatic  principles  without  going  straight 
to  the  root  of  the  matter  and  rectifying  the  underlying  atony.  If  these 
principles  be  clearly  understood  we  may  now  consider  the  means  for 
relieving  the  pain  or  the  distress  which  the  hyperacidity  causes,  by  purely 
symptomatic  treatment,  irrespective  of  the  actual  underlying  cause. 

Medical  Treatment. — The  chemical  antidote  for  acidity  is  an  alkali. 
Bicarbonate  of  soda  is  perhaps  the  most  useful,  certainly  the  one  most 
commonly  employed  for  this  purpose.  Soda  may  be  given  in  doses  from 
one-fourth  to  one-half  a  teaspoonful  in  water  at  the  time  of  the  greatest 
distress,  or  soda  mints  or  the  lozenges  containing  15  to  20  grains  of  the 
preparation  may  be  carried  in  the  pocket  and  slowly  dissolved  as  needed. 
There  is  much  popular  objection  to  the  use  of  the  remedy,  but  the  writer 
believes  that  the  lesser  evil  lies  in  the  reduction  of  excessive  acid  and 
sees  no  objection  to  its  reasonable  use  even  over  long  periods  of  time. 
Alkaline  earths  and  carbonates  are  of  service.  ]\Iagnesium  oxide  or 
the  calcined  magnesia  is  a  valuable  antacid  and  serves,  moreover,  to 
produce  a  laxative  effect.  Subcarbonate  of  l)ismuth  is  most  serviceable 
in  irritative  conditions  of  the  stomach  such  as  accompany  ulcer,  or 
when  the  hyperacidity  is  accompanied  by  vomiting  or  diarrhea,  and 
may  be  combined  in  varied  proportions  with  magnesia  and  soda. 
Sodium  citrate  in  teaspoonful  doses  may  be  given  between  meals, 
often  with  brilliant  results.  Calcium  carbonate  may  be  used  either 
in  i)o\vder  form  or  in  suspension. 

The  following  prescriptions  have  been  of  service,  and  the  ingredients 
can  be  arranged  in  a  variety  of  ways  to  meet  indixidual  recpiirements. 

I^ — Magnesia  usta gr.  iij 

Bismuth  subcarbonate gr.  v 

iSodii  bicarl)()nate gr.  xv 

M.    Sig. — Such  a  powder  two  liours  after  eating. 

I^ — Cerium  oxalate, 

Bismuth  subcarbonate afi     gr.  v 

Magnesia  usta gr.  iij 

Sodium  bicarbonate ad     gr.  xxx 

M.    Sig. — Such  a  powder  whenever  heart -l)urn  occurs. 

I^ — Orthoform, 

Bismuth  subcarbonate M     gr.  x 

Mist,  creta;  comp ad     oj 

M.    Sig. — Teaspoonful  in  a  httle  water  for  indigestion. 


TREATMENT  OF  HYPERACIDITY  477 

It  must  be  remembered,  however,  that  these  alkaline  powders  are 
merely  symptomatic  in  their  use. 

Alkaline  ivaters  may  be  recommended,  although  if  atony,  gastrop- 
tosis,  or  pyloric  contraction  be  present,  they  should  be  allowed  only 
in  minimum  doses  if  at  all. 

The  best  waters  for  such  purposes  are  the  Saratoga  Mchy,  Witter 
Water  Spring,  or  in  Europe  Fachingen,  Giesshiibel,  or  Vichy.  These 
waters  are  to  be  preferably  warmed.  They  may  be  taken  before  break- 
fast, or  at  any  time  that  an  antacid  is  needed  for  relief.  The  writer 
has  seen  no  beneficial  effects  from  their  use  as  a  "cure,"  but  has  noticed 
considerable  betterment  in  the  distress  of  hyperacid  patients  when 
the  water  is  taken  simply  as  a  temporary  means  of  relief,  but  they 
possess  no  advantage  over  the  alkaline  powders  ordinarily  prescribed 
for  the  same  purpose. 

Carlsbad  water  may  be  of  service  in  hyperacidity  due  to  ulcer  or  to 
gall-bladder  infections,  or  resulting  from  chronic  gastritis.  In  these 
instances  a  glass  of  Sprudel  as  hot  as  can  be  sipped  should  be  taken 
on  arising  in  the  morning,  at  least  three-quarters  of  an  hours  before 
breakfast,  and  possibly  half  such  a  dose  may  be  taken  an  hour  before 
the  evening  meal.  The  quantity  taken  should  be  so  limited  that  only 
one  loose  movement  of  the  bowels  results. 

Either  the  imported  water  may  be  taken,  or  the  artificial  salt  may  be 
used  suitably  diluted.  The  powder  obtained  by  the  evaporation  of 
the  Sprudel  water  at  the  spring  is  the  best  form  in  the  market,  and  is 
imported  by  Eisner  and  Mendelson  in  this  country.  The  dose  is  a 
level  teaspoonful  to  a  tumbler  of  water.  Sodium  chloride  waters, 
such  as  Hawthorne  and  Congress  water,  and  in  Europe  Kissingen, 
Homburg,  Soden,  and  Wiesbaden  are  positively  contraindicated. 

Belladonna  and  atropine  have  been  recommended  because  of  their 
effect  in  inhibiting  excessive  secretion,  but  unfortunately  to  produce 
such  a  result  the  drug  must  be  given  in  such  doses  that  unpleasant 
physiological  effects  may  require  its  discontinuance.  The  writer  has 
employed  both  small  repeated  doses  of  the  tincture  of  belladonna 
(Tlliij  to  V,  t.  i.  d.)  or  minute  doses  of  atropine  (gr.  2"4Tr,  t.  i.  d.,  or 
gr.  -51)0  every  three  hours),  but  has  generally  been  disappointed  in  the 
results.    The  remedy  has  usually  been  worse  than  the  disease. 

Olive  oil  has  been  recommended,  owing  to  its  supposed  inhibitory 
effects  upon  gastric  secretion.  A  tablespoonful  may  be  administered 
half-hour  before  the  meals  or  half  a  wineglass  (5j  to  oij)  may  be  given 
on  retiring.  When  hyperacidity  is  due  to  pylorospasm  from  gastric 
or  duodenal  ulcers  or  abrasions  the  results  of  the  oil  treatment  are 
generally  very  good,  but  in  hyperacidity  otherwise  induced,  the  treat- 
ment has  seemed  most  disappointing. 


478  HYPERACIDITY 

Silver  nitrate  has  been  long  regarded  as  serviceable  in  reducing 
acidity.  Whether  or  not  actual  reduction  in  total  acidity  of  subsequent 
test  breakfasts  can  be  demonstrated  is  problematical,  but  the  drug 
certainly  does  seem  to  relieve  in  great  measure  the  discomfort  of  the 
disorder.  Silver  nitrate  may  be  given  in  solution,  capsule,  or  by  lavage. 
The  dose  of  the  drug  by  mouth  is  about  gr.  ^,  t.  i.  d.,  and  it  may  be  given 
either  in  solution  or  in  capsule.  A  useful  method  is  that  by  cycles  of 
gradual  increase  in  the  dose.  For  three  days  gr.  ^  are  given  in  distilled 
water  half-hour  before  the  meals — for  the  following  three  days  gr.  | 
are  similarly  given,  while  in  the  last  three  days  of  the  cycle  the  dose 
is  increased  to  gr.  f .  After  the  lapse  of  three  days  the  cycle  is  to  be 
repeated.  Should  diarrhea  occur  the  dose  should  be  reduced  or  the 
treatment  abandoned.     The  following  prescription  may  be  employed: 

I^ — Argenti  nitrat gr.  xxxij 

Aq.  destillatse §ij 

M.  Sig. — 5  minims  contain  gr.  '  of  silver  nitrate.  Dose  15  to  2.5  drops  well 
diluted  with  distilled  water  one-half  hour  before  meals. 

Lavage  with  s^oVo  solution  of  the  nitrate  may  be  found  distinctly 
serviceable.  The  stomach  should  first  be  washed  with  ordinary  water 
until  the  return  flow  is  clear,  and  then  with  about  2  pints  of  the  silver 
solution,  taking  care  that  as  little  as  possible  of  the  solution  remains 
in  the  .stomach.  This  treatment  may  be  given  every  second  day,  and 
should  be  discontinued  temporarily  if  diarrhea  occurs.  If  seemingly 
beneficial  the  strength  may  be  gradually  increased  to  1  to  1500,  but 
greater  concentrations  than  this  are  not  to  be  used.  In  making  a  .solu- 
tion of  1  to  3000,  5j  of  the  above  prescription  to  the  pint  of  water  is 
sufficiently  accurate. 

Aluminum  salicylate  has  been  highly  recommended  by  Rosenheim 
of  Berlin  in  doses  of  half  to  one  teaspoonful  shaken  with  water  about 
half  to  one  hour  before  meals.  The  drug  is  in  the  market  under  the 
name  of  Xeutralon  (Kaulbaumj — a  fine  odorless  and  tasteless  powder, 
insoluble  in  water.  The  writer  has  had  no  experience  with  this 
drug. 

Of  late  the  use  of  hydrogen  peroxide  has  been  warmly  indorsed. 
Fifty  cubic  centimeters  of  a  3  per  cent,  solution  are  made  up  to  300  c.c. 
with  water,  making  approximately  0.5  per  cent,  solution.  A  similar 
dilution  may  be  obtained  by  using  5]  of  the  3  per  cent,  peroxide  in  a 
tumblerful  of  water.  A  glassful  should  be  taken  an  hour  after  meals. 
Goodman,  writing  from  the  laboratory  of  the  late  Dr.  John  H.  Musser, 
is  a  strong  advocate  of  this  treatment.  In  the  author's  cases  consider- 
able relief  to  the  heart-burn  and  distress  may  be  expected,  although 
he  has  not  been  able  to  satisfy  him.self  that  any  permanent  reduction 


TREATMENT  OF  HYPERACIDITY  479 

in  the  total  acidity  of  the  gastric  contents  follows  the  treatment.  The 
objection  to  the  water  is  the  fishy  taste.  Similar  results  may  be 
obtained  by  perhydrol  in  teaspoonful  doses,  although  less  certain 
than  with  the  peroxide  water. 

Hyperacidity  due  to  atony  even  after  it  has  resisted  ordinary  treat- 
ment may  be  relieved  by  large  doses  of  the  tincture  of  mix  vomica. 
The  drug  must  be  given  in  ascending  doses  and  in  large  quantities,  and 
generally  over  long  periods  of  time,  usually  four  or  five  months.  The 
late  Dr.  John  H.  Musser  recommended  that  in  most  cases  60  or  more 
drops  three  times  daily  should  be  given,  although  the  point  of  toler- 
ance should  be  computed  for  each  individual.  Xux  vomica  and  not 
strychnine  should  be  used. 

Dietetic  Treatment. — The  choice  of  diet  depends  upon  the  underh^ing 
cause  for  the  hyperacidity.  If  ulcer  be  the  primal  cause,  the  diet  is 
that  of  ulcer,  while  in  atony  and  atonic  gastroptosis  the  diet  appropriate 
to  these  conditions  is  to  be  enforced,  ^^^len  chronic  appendicitis  is 
the  cause,  no  lasting  benefit  can  result  from  diet  regulations,  although 
attacks  of  pylorospasm  may  in  all  probability  be  rendered  less  frequent 
and  less  severe  by  the  enforcement  of  a  diet  that  is  mechanically  bland 
and  unirritating.  In  general  starches  should  be  somewhat  reduced  and 
the  fats,  in  the  form  of  cream  and  fresh  butter  correspondingly  increased. 
Such  a  diet  may  be  constructed  on  the  following  scheme: 

Breakfast  : 

None:  Coffee  not  advised;  no  tea  allowed;  no  coarse  cereal,  such 
as  oatmeal  or  cracked  wheat;  no  bread  crusts,  dry  toast,  or  hot  bread; 
no  salt  fish  or  potatoes. 

Allowed:  Cocoa,  with  cream  and  sugar.  Fine  cereal,  such  as  cream 
of  wheat,  farina,  etc.  Soft  parts  of  bread,  milk,  or  cream  toast.  Crackers 
thoroughly  masticated.  Butter,  preferably  unsalted,  to  be  taken  as 
freely  as  possible.  Creamed  or  minced  chicken;  fresh  fish;  soft-boiled 
or  poached  eggs. 

Luncheon: 

Puree  or  cream  soup  of  any  kind,  made  without  meat  stock;  no 
other  soups  allowed.  Lamb;  simply  prepared  ragout;  lean  broiled  or 
boiled  ham;  fish,  chicken,  oysters  in  any  form.  Fowl,  except  domestic 
duck  or  goose.  Mashed  or  baked  potatoes;  spaghetti  or  macaroni. 
Any  vegetable  that  can  be  put  through  a  puree  sieve  allowed.  Any 
green  vegetable  (such  as  string  beans)  may  be  taken  if  tender,  not  if 
tough.  Salad,  with  French  dressing,  made  with  lemon.  Farinaceous 
desserts,  such  as  rice  pudding,  corn-starch,  blanc-mange,  custard,  etc. 
No  ice-cream  or  ices.  No  fruit  of  any  kind.  Alcohol  not  allowed  in 
any  form. 

Cheese:    Camembert,  Roquefort,  Cream,  Brie.  Neufchatel,  pot-cheese. 


480  HYPERACIDITY 

Dinner: 

Same  variety  as  for  lunch. 

Between  meals  may  be  taken:  Choice  of  custard,  junket,  raw  eggs 
or  egg  and  milk  shake,  chicken  or  meat  sandwich;  malted  milk,  cocoa. 
jNIilk  in  the  glass  not  allowed. 

Seasoning,  such  as  pepper,  salt,  paprika,  etc.,  should  be  reduced  to 
the  minimum. 

Water  should  be  cool  but  not  iced;  Celestins  or  Saratoga  Vichy, 
Fachingen,  Apollinaris  or  Giesshiibler  preferable  to  plain  water;  when 
these  waters  cannot  be  obtained,  may  drink  water  containing  one 
quarter  of  a  teaspoonful  of  bicarbonate  of  soda  to  the  glass. 

The  danger  is  that  the  dieting  is  often  overdone  and  the  patients  are 
so  restricted  that  they  are  not  allowed  enough  food  to  keep  up  their 
general  strength.  In  the  writer's  experience  this  danger  is  real,  not 
fanciful,  and  especially  in  the  atonic  cases  much  harm  may  ultimately 
result. 

The  writer  has  seen  no  special  results  from  the  adoption  of  a  salt- 
free  diet. 


CHAPTER   XVIII 
ACHYLIA 

Under  the  term  "achylia  gastrica"  are  included  those  conditions 
in  which  hydrochloric  acid  is  absent  both  in  a  free  and  combined  form 
from  the  gastric  juice.  Properly  speaking  the  term  should  be  limited 
to  those  cases  only  in  which  neither  acid  nor  ferments  are  found  in  the 
stomach  contents,  or  as  Martins  expresses  it,  "When  the  gastric  juice 
is  deficient  in  all  of  its  ingredients."  Clinically,  however,  we  find  very 
few  cases  in  which  this  double  deficiency  exists.  Acid  secretion  and 
ferment  secretion  are  two  distinct  results  of  glandular  activity  and  quite 
independent  of  each  other.  In  general  it  may  be  said  that  the  acid 
secretion  is  far  more  easily  checked  than  is  the  elaboration  of  the  fer- 
ments, so  that  we  usually  find  that  even  with  entire  absence  of  hydro- 
chloric acid  the  ferments  are  present,  although  they  may  be  secreted 
in  diminished  amounts.  It  is  only  in  the  most  extreme  instances  of 
atrophy  of  the  entire  glandular  elements  of  the  stomach  that  total 
absence  of  ferments  exist,  so  that  if  the  term  were  strictly  used,  it  would 
apply  to  only  a  very  small  proportion  of  the  cases  in  which  tests  show 
an  absence  of  acid  secretion.  The  term,  therefore,  is  used  clinically 
in  the  broader  sense  of  implying  only  an  absolute  hydrochloric  defi- 
ciency in  the  gastric  juice,  and  is  very  convenient  to  use  as  it  covers 
a  class  of  cases  in  which  achlorhydria  occurs  from  such  a  variety  of 
causes,  some  definite,  others  obscure,  that  an  orderly  classification  on 
pathological  grounds  cannot  be  made. 

Forms. — Achylia  may  occur  both  in  malignant  and  in  non-malignant 
disease. 

Malignant  Achylia.  —  In  2500  private  patients  with  stomach  and 
intestinal  disorders,  149,  or  6  per  cent.,  showed  achylia  that  was  not  due 
to  cancerous  disease  of  the  stomach.  During  this  same  period  of  time 
there  were  40  cases  of  cancer,  of  which  gastric  analysis  was  made  in  IS. 
Of  these  18  cases,  in  only  4  was  there  a  true  achylia  present  without 
evidences  of  malignancy  in  the  test  breakfast,  such  as  lactic  acid, 
blood,  Oppler-Boas  bacilli,  or  food  stagnation.  Therefore,  of  153  con- 
secutive cases  of  apparently  simple  achylia  only  4  were  malignant. 
These  figures  are  interesting  as  tending  to  disapprove  of  the  old  idea 
that  absence  of  hydrochloric  acid  meant  malignancy.  It  cannot  be 
affirmed  too  positively  that  the  presence  or  absence  of  hydrochloric 
acid  has  very  little  bearing  upon  the  diagnosis  of  gastric  cancer.  Achylia 
31 


482  ACHY  LI  A 

occurring  in  malignant  disease  of  the  stomach  is  described  in  chapter 
on  Cancer. 

Nature  and  Pathology. — Achylia  may  occur  from  a  variety  of  causes 
which  may  be  roughly  grouped  as  follows: 

1.  Achylia  from  inflammatory  processes  in  the  stomach  with  or 
without  atrophic  changes. 

2.  Achylia  from  atrophic  changes  in  the  gastric  mucosa  not  definitely 
consequent  upon  an  accompanying  inflammation. 

3.  Achylia  as  the  result  of  the  lack  of  functional  activity  of  the 
secretory  glands  of  the  stomach,  either  as  a  pure  neurosis  or  reflex 
inhibition  of  function  from  primary  forms  of  nerve  irritation. 

Achylia  as  the  Result  of  Gastric  Catarrh  with  or  without  Trophic  Changes. 
— There  is  no  doubt  that  gastritis  exists  in  a  large  number  of  cases  of 
anacidity.  The  German  writers  consider  that  this  is  by  far  the  most 
frequent  form,  and  that  anacidity,  furthermore,  in  gastric  catarrh 
represents  the  terminal  stage  of  the  inflammation  attended  by  the 
destruction  of  the  gastric  tubules,  so  that  secretion  of  these  products  is 
no  longer  possible.     This  opinion  is  well  expressed  by  Eisner  as  follows: 

"In  the  great  majority  of  cases  achylia  is  occasioned  by  an  organic 
disease  of  the  glands  of  the  stomach  due  to  a  chronic  inflammatory 
process  of  a  catarrhal  nature  which  has  resulted  in  complete  destruction 
of  the  secreting  apparatus  and  in  atrophy  of  the  mucous  membrane. 
It  is  the  clinical  expression  for  'anadenia  gastrica.'  All  injuries  which 
can  provoke  chronic  catarrh  are  equally  etiological  factors  in  achylia. 
Among  these  may  be  mentioned  an  unsuitable  and  improper  diet, 
abuse  of  tobacco  and  alcohol,  defective  teeth,  and  imperfect  mastica- 
tion as  well  as  habits  of  hasty  and  rapid  eating."  According  to  this 
writer  the  disease  is  more  common  among  the  poorer  classes  than 
among  those  in  comfortable  circumstances. 

With  these  views  the  writer  can  agree  in  but  a  part  only.  There  is 
no  doubt  that  in  the  majority  of  cases  of  alcoholic  gastritis  the  general 
trend  of  the  disease  is  toward  a  progressive  reduction  of  secretory  and 
peptic  power  which  becomes  most  marked  whenever  cirrhosis  inter- 
venes, and  which  is  due  to  the  effect  of  the  progressive  inflammation. 
Even  in  these  cases,  however,  the  clinical  evidence  of  achylia  may  not 
be  associated  with  pathological  changes  in  the  gastric  mucosa  to  account 
for  the  absence  of  secretory  power.  The  glands  seem  normal  enough  to 
have  done  their  work,  but  why  they  have  not  done  so  we  cannot  say. 

In  the  forms  of  gastritis  that  are  not  due  to  overindulgence  in  alcohol, 
it  is  in  rare  instances  only  that  we  can  obtain  a  clinical  history  of  gastric 
catarrh.  The  patients  are  usually  well  nourished,  and  are  neither 
enfeebled  nor  anemic.  They  deny  having  had  previous  gastric  distress, 
nor  is  it  possible  to  elicit  the  history  of  previous  symptoms  of  heart-burn 


NATURE  AND  PATHOLOGY  OF  ACHY  LI  A  483 

SO  characteristic  of  the  hyperacid  cases.  Of  a  certain  number,  gastric 
analyses  show  the  presence  of  mucus  in  such  quantities  that  the  origin 
of  achyHa  in  a  gastric  catarrh  cannot  be  disputed,  but  these  form  only 
a  small  proportion  of  the  achylia  cases,  as  "wet  achylia"  or  the  form 
of  test  breakfast  in  which  undigested  bread  fragments  are  obtained 
floating  in  mucus,  occurs  in  but  30  per  cent,  of  the  total  number  of 
cases  of  achlorhydria.  The  more  usual  forms  of  gastric  contents  in 
which  only  small  quantities  of  mucus  are  present  enveloping  and  in- 
filtrating the  food  fragments  cannot  be  considered  as  a  proof  of  the 
catarrhal  origin  of  the  disease,  for  the  reason  that  the  secretion  of  mucus 
may  be  only  the  result  entirely  of  the  irritation  of  the  gastric  mucous 
membrane  by  food  that  is  totally  undigested  by  reason  of  a  primary 
achylia.  On  the  other  hand,  the  absence  of  mucus  cannot  exclude 
gastric  catarrh  because  the  mucus  secreting  glands  may  be  involved  in 
the  same  inflammatory  process  that  has  destroj^ed  the  glands  whose 
function  it  is  also  to  secrete  acid  and  digestive  ferments. 

Again  it  must  be  remembered  that  latency  in  gastric  catarrh  occurs 
even  with  definite  and  well-marked  pathological  changes  in  the  mucosa, 
and  that  gastritis  even  if  severe  from  an  anatomical  standpoint  may 
exist  for  years  without  the  least  clinical  evidence  of  its  presence. 

The  above  are  the  clinical  reasons  why  it  is  difficult  to  accept  without 
reserve  the  view  that  achylia  owes  its  origin  to  severe  and  continued 
gastric  inflammation. 

Lange  and  Faber,^  on  the  other  hand,  in  a  recent  article,  after  a  most 
careful  pathological  study  of  sections  of  the  stomach  in  achylia  in 
which  postmorten  change  had  been  prevented  by  the  intra-abdominal 
injection  of  10  per  cent,  formalin  solution  immediately  after  death, 
conclude  that  while  a  purely  functional  origin  of  achylia  cannot  be  dis- 
puted, it  occurs  but  rarely — as  in  their  experience  chronic  inflammatory 
changes  in  the  mucosa  were  almost  regularly  present  and  consisted  in  a 
chronic  interstitial  inflammation,  together  with  the  parenchymatous 
changes  common  to  gastric  catarrh.  Atrophic  changes  in  their  cases 
were  not,  however,  prominent.  In  twelve  cases,  atrophic  changes  were 
considerable  in  but  two,  moderate  in  one,  insignificant  in  nine.  They 
conclude  that  in  practically  all  of  the  cases  of  achylia,  gastritis  is  present, 
but  that  the  degree  of  anatomical  change  cannot  serve  as  an  indication 
of  the  amount  of  functional  disturbance  resulting  from  it.  They  allude 
to  the  fact  that  in  acute  catarrh  of  the  stomach  in  which  pathological 
changes  in  the  mucosa  are  much  less  marked  than  in  achylia,  functional 
derangements  may  be  profound.  This  seems  to  the  writer  to  be  the 
weak  point  in  all  the  conclusions  drawn  from  the  pathological  study 

1  Zeitsch.  f.  klin.  Med.,  1908,  Ixvi,  pp.  53  and  247. 


484      .  ACHY  LI  A 

of  achylia — that  the  degree  of  atrophy  is  not  enough  to  explain  the  loss 
of  function  on  any  pathological  basis.  Moreover,  it  is  possible  that  the 
gastric  catarrh  results  from  the  irritation  of  undigested  food  within  the 
stomach  instead  of  being  the  primary  cause  for  the  achylia. 

In  their  studies  of  7  cases  of  achylia  with  pernicious  anemia,  Lange 
and  Faber  report  that  the  prominent  feature  was  inflammation  of  the 
mucosa,  especially  of  the  interstitial  type,  as  shown  by  cellular  infiltra- 
tion throughout  the  mucosa,  but  especially  well-marked  near  the  surface, 
while  the  glandular  structures  were  well  preserved.  They  conclude 
that  the  prominent  gastric  lesion  in  pernicious  anemia  is  gastritis,  and 
that  atrophy  is  in  no  sense  essential. 

The  writer  would  suggest  that  it  is  not  improbable  for  achylia  to 
develop  in  various  forms  of  toxemia,  the  lesions  of  chronic  gastric 
catarrh  being  the  pathological  result  of  the  toxins,  while  functional 
acti\'ity  is  checked  by  the  toxic  products  present  in  the  blood  acting 
locally  upon  the  secretory  apparatus  of  the  mucous  membrane  of  the 
stomach.  It  is  possible  that  the  unknown  toxins  of  pernicious  anemia, 
together  with  the  products  of  hemolysis  common  to  this  disease,  may 
serve  as  an  excitor  of  gastric  catarrh  and  as  a  depressor  of  gastric 
f miction.  The  achylia  that  often  accompanies  bothriocephalus  anemia 
may  be  caused  in  the  same  manner.  The  toxemias  of  chronic  Bright's 
disease  and  of  chronic  pulmonary  tuberculosis  might  likewise  possibly 
cause  the  achylia  that  so  often  accompanies  these  diseases.  The 
close  connection  that  clinically  exists  between  achylia  and  infections 
of  the  gall-bladder  might  according  to  this  reasoning  be  explained  by 
the  toxins  of  the  former  infection  acting  upon  the  mucous  membrane 
of  the  stomach. 

The  weak  point  in  the  writer's  suggestion  is  the  fact  that  after  the 
cure  of  the  primary  disease  and  complete  elimination  of  the  toxins, 
the  gastric  functions  are  but  rarely  resumed.  Thus,  some  of  the  cases 
of  bothriocephalus  anemia  are  followed  by  persistent  achylia  even  after 
the  expulsion  of  the  parasite  and  the  cure  of  the  anemia. 

Faber  and  Lange  believe  that  whenever  an  achylia  that  has  existed 
for  years  is  succeeded  by  a  return  to  normal  secretion,  there  has  been 
ett'ected  a  cure  of  the  chronic  gastritis  to  which  the  achylia  owed  its 
origin.  When  we  consider,  however,  that  in  three-quarters  of  the  cases 
studied  by  these  authorities  atrophic  changes  were  insignificant,  and 
the  amount  of  anatomical  changes  in  the  nnicosa  quite  inconsiderable, 
we  must  confess  that  we  know  very  little  indeed,  if  in  fact  we  know 
anything  at  all,  about  the  pathology  of  achylia. 

It  is  a  well-recognized  fact  that  the  mucous  membrane  of  the  stomach 
in  achylia  is  exceedingly  \uliierable  and  that  small  bits  and  fragments 
are  easilv  detached  b\  the  v\c  of  the  stomach  tube  and  are  found  either 


NATURE  AND  PAmOLOdY  OF  ACJIYLJA  485 

in  the  test  breakfast  or  in  tlie  lavage  water.  Exaniiiiatioiis  of  these 
fragments  have  frequently  been  made,  but  while  a  certain  innnber  show 
the  i)resenee  of  inflammatory  changes,  many  again  are  apparently 
normal  and  it  is  significant  that  Lubarsch  who  has  certainly  done  as 
much  work  in  this  direction  as  any  other  man,  working  in  conjunction 
with  Martius,  should  warn  us  that  we  are  not  justified  in  drawing 
conclusions  about  the  condition  of  the  stomach  as  a  whole  by  any 
examination  made  of  a  small  bit  of  mucous  membrane  whose  pre^•ious 
location  in  the  stomach  is  unknown. 

Achylia  Resulting  from  Atrophic  Changes  in  Stomach. — Achylia  riunj 
result  from  atrophic  changes  in  the  stomach  that  are  not  definitely  con- 
sequent upon  inflammatory  processes.  Of  this  form  two  distinct  types 
are  recognized: 

1.  Atrophy  of  gastric  tubules  may  occur  with  pernicious  anemia, 
and  is  generally  considered  at  the  present  time  to  be  the  result  of  the 
blood  changes  of  that  disease  rather  than  the  cause  for  the  anemia. 

At  variance  w'ith  this  view,  however,  are  the  results  of  pathological 
studies  in  achylia  accompanying  pernicious  anemia  by  Faber  and  Lange 
who  found  in  7  cases  sectioned  by  them  that  the  prominent  pathological 
change  in  the  mucosa  was  one  of  interstitial  inflammation  and  that  the 
glands  were  well  preserved,  so  that  atrophy  could  not  be  regarded  as  an 
essential  lesion.    Further  studies  on  this  point  are  necessary. 

It  is  not  known  w^hether  the  achylia  that  accompanies  various  forms 
of  toxemia,  such  as  bothriocephalus  anemia,  chronic  pulmonary  tuber- 
culosis and  chronic  nephritis  are  to  be  explained  by  atrophy,  by  chronic 
gastritis  secondary  to  these  diseases,  or  by  a  functional  inhibition  of 
secretion. 

Atrophic  changes  occur  with  cancer,  either  occurring  locally  in  the 
stomach  or  in  some  organ,  however  far  distant.  In  both  these  in- 
stances the  cause  for  the  atrophy  is  probably  some  form  of  toxemia 
or  hemolysis  at  present  unknown  to  us. 

2.  A  very  different  type  is  the  form  of  chronic  producti\'e  inflam- 
mation and  atrophy  that  occur  in  elderly  subjects  and  is  analogous  in 
its  essential  nature  to  other  forms  of  senile  degeneration  and  arterio- 
sclerosis common  to  those  of  advancing  years. 

Soltau  Fenwick^  has  described  these  cases  and  gi^'es  the  following 
description  of  the  pathological  changes  that  are  manifest.  The  lesions 
usually  begin  after  fifty,  although  they  may  be  present  even  before 
this  time.  The  pyloric  portion  of  the  stomach  appears  attenuated, 
the  rugfe  absent,  and  the  mucous  membrane  smooth  and  generally 
adherent  to  the  muscular  coat.    There  may  be  glistening  streaks  ruiniing 

1  Lancet,  November  6,  1909,  p.  1347. 


486  ACHY  LI  A 

parallel  with  the  lesser  curvature  or  irregular  particles  of  this  scar- 
like  tissue  over  the  mucous  membrane  near  the  pylorus.  Extensive 
atheromatous  changes  of  the  aorta,  coronary,  and  mesenteric  arteries 
are  usually  observed. 

Microscopical  examination  shows  a  growth  of  connective  tissue  sur- 
rounding the  glands  so  that  the  latter  appear  unduly  separated  from 
one  another.  As  the  disease  progresses,  the  increasing  interstitial 
tissue  twists,  distorts,  and  compresses  the  glandular  structures  until 
they  finally  disappear,  leaving  the  mucous  membrane  converted  into 
a  thin  layer  of  fibrous  tissue.  The  submucosa  suffers  from  the  same 
form  of  cirrhosis  with  obliterating  endarteritis  of  the  nutrient  vessels. 
There  are  no  evidences  of  hyperemia  for  any  part  of  the  process; 
similar  lesions  may  be  noticed  in  the  small  intestine. 

Fig.   99 


Atrophic  form  of  stomach  common  in  (ddorly  subjects.    The  grof-s  characteristics  as  described  by 
Fenwick  are  well  represented. 

Fenwick  estimates  that  21  per  cent,  of  those  over  sixty-fi\e  suffer 
from  chronic  indigestion,  of  100  such  cases  (K)  per  cent,  are  secondary 
to  organic  disease,  including  10  per  cent,  whose  indigestion  is  due  to 
hypersecretion  the  result  of  chronic  ulcer,  gallstones  or  chronic  appen- 
dicitis. The  symptoms  of  tlie  remaining  34  per  cent,  are  due  to  the 
progressive  atrophy  of  the  gastric  mucosa  just  described. 

Achylia  was  found  by  Stockton  in  37  per  cent,  of  his  examinations 
in  those  over  fifty,  by  Seidelin  in  40  ])er  cent,  under  similar  conditions. 

The  author  annexes  two  tables  showing  the  relation  of  achylia  to 
the  N'arious  stages  of  life,  taken  from  the  records  of  his  ])ri\'ate  cases. 


NATURE  AND  PATHOLOGY  OF  ACHY  LI  A  487 

In  the  first  table  are  given  the  percentage  in  which  achylia  is  found 
in  the  different  decades  among  those  applying  for  treatment  for  various 
digestive  disorders. 

In  the  writers's  series  of  achylia 

1  per  cent,  occurred  between  the  ages  of  10  and  20  years 
5  per  cent,  occurred  between  the  ages  of  20  and  30  years 

25  per  cent,  occurred  between  the  ages  of  30  and  40  years 
33  per  cent,  occurred  between  the  ages  of  40  and  50  years 
20  per  cent,  occurred  between  the  ages  of  50  and  60  years 
14  per  cent,  occurred  between  the  ages  of  60  and  70  years 

2  per  cent,  occurred  between  the  ages  of  70  and  80  years 

This  table  brings  out  the  relative  frequency  of  achylia  in  the  various 
ages  that  apply  for  medical  treatment.  The  number  of  patients  over 
fifty  or  sixty  who  apply  for  treatment  is  relatively  smaller  than  those 
of  less  advanced  years  of  life  because  there  are  fewer  of  them. 

In  the  succeeding  table  the  writer  has  taken  100  patients  in  each 
decade  who  have  gastro-intestinal  symptoms  and  in  whom  gastric 
analysis  has  been  made  to  see  how  many  of  these  have  achylia,  wdth 
the  following  result: 

Between  20  and  30  years 4  per  cent. 

Between  30  and  40  years 12  per  cent. 

Between  40  and  50  years 11  per  cent. 

Between  50  and  60  years 24  per  cent. 

Between  60  and  70  years 36  per  cent. 

The  writer  is  inclined,  therefore,  to  believe  that  estimates  of  Fenwick 
and  Stockton  are  rather  under  the  mark  and  that  60  per  cent,  of  these 
over  fifty  show  by  gastric  analyses  that  achylia  is  present,  although 
in  a  large  proportion  of  these  the  disorder  may  run  its  course  without 
symptoms. 

Achylia  Due  to  Functional  Derangement. — Achylia  is  frequently  found 
in  cases  in  which  structural  changes  in  the  mucous  membrane  of  the  stomach 
are  suggested  neither  by  the  clinical  history  nor  by  the  physical  examination 
of  the  patient,  and  we  are  compelled  to  include  these  unexplained  cases  under 
the  general  heading  of  secretory  neuroses.  There  is  no  doubt  but  that 
achylia  may  exist  as  a  purely  functional  derangement,  and  the  absence 
of  hydrochloric  acid  in  the  gastric  juice  may  be  followed,  within  a 
short  period  of  time,  by  a  recurrence  of  its  secretion,  without  treatment, 
nor  any  change  in  the  diet  or  mode  of  life  of  the  patient.  These  cases 
are  frequently  termed  "  heterochylia."  The  disappearance  of  the  hydro- 
chloric acid  in  these  patients  is  usually  but  temporary,  the  patients 
are  usually  neurotic  in  temperament,  and  the  recurring  acidity  is  often 
abnormally  excessive. 


4SS  ACHY  LI  A 

Temporary  achylia  may  occur  as  the  result  of  sudden  ner\'ous  shocks, 
or  of  acute  depressed  mental  conditions.  This  mode  of  occurrence  is 
frequently  seen  in  those  who  suffer  from  great  nervous  excitement  from 
whatever  cause,  and  in  this  condition,  sit  down  to  their  meals — suffer- 
ing for  some  hours  afterward  from  epigastric  distress,  nausea,  and  the 
\omiting  of  the  food  taken  at  the  previous  meal,  totally  undigested 
and  without  trace  of  hydrochloric  acid  either  free  or  combined. 
Temporary  achylia  occurs  so  frequently  just  before  or  during  the  first 
day  of  menstruation  that  gastric  analysis  should  never  be  made  at 
this  time  if  it  can  be  avoided,  as  the  chemical  findings  are  apt  to  be 
misleading. 

Far  different,  however,  are  the  cases  in  which  achylia  without  known 
cause  continues  steadily  and  without  change  for  months  and  years,  for 
it  is  an  established  fact  that  persistent  achylia  can  occur  in  this  way 
without  structural  changes  in  the  secreting  apparatus  of  the  stomach. 

The  writer  remembers  especially  one  patient  in  whom  achylia  of 
the  dry  variety  had  persisted  to  his  knowledge  for  years.  The  chief 
complaint  was  of  pain,  due  to  adhesions  between  the  gall-bladder  and 
lesser  curvature,  for  the  relief  of  which  an  operation  was  performed, 
the  patient  dying  on  the  seventh  day  from  hemorrhage  into  the  pons. 
Specimens  snipped  from  the  stomach  wall  at  the  time  of  operation  and 
sections  made  in  various  parts  of  the  organ  after  death,  preserved  from 
j)ostmortem  changes  by  the  filling  of  the  stomach  with  formalin  solu- 
tion a  few  moments  after  death,  failed  to  reveal  the  least  evidence 
of  disease,  and  were  regarded  by  the  late  Dr.  Hodenpyl  as  absolutely 
normal  in  e^'ery  particular. 

The  origin  of  these  cases  cannot  be  explained — the  absence  of  organic 
changes  in  the  stomach  would  seem  to  imply  that  they  were  purely 
functional,  but  on  the  other  hand  it  is  inexplicable  that  a  person  who 
is  as  api)arently  well  and  healthy  as  are  most  of  the  achylia  patients, 
and  Avithout  any  evidences  of  nervous  instability,  should  go  along  year 
after  year  with  a  ner\'ous  suppression  of  gastric  juice  as  the  one  and  only 
functional  derangement  that  we  can  detect.  It  is  unlike  a  systemic 
neurosis  to  focus  itself  u])on  one  body  function  for  so  long  a  time, 
without  causing  other  and  varying  functional  derangements.  No 
other  secretion  of  the  body  is  affected  in  like  manner.  Patients  with 
achylia  as  a  class  are  not  more  nervous  than  are  a  similar  number  of 
patients  taken  at  random,  neither  does  it  seem  that  the  predisposition 
of  women  to  the  disease  is  sufficiently  great  to  suggest  a  neurotic  origin. 
Under  fifty  the  disease  occurs  in  women  in  proportion  2  to  1,  while 
after  this  age  the  sexes  are  nearly  equally  represented. 

The  view  that  achylia  is  the  manifestation  of  a  primary  neurosis 
is  supported  therefore  by  insufficient  evidence. 


NATURE  AND  1>  AT  HO  LOGY  OF  ACHY  LI  A  489 

It  has  been  suggested  that  instead  of  achylia  l)eing  a  j^rimary  neurosis, 
the  seeretion  of  gastric  juice  may  be  inhibited  by  reflex  action  from  a 
primary  source  for  irritation,  at  some  point  more  or  less  distant,  a  point 
of  view  suggested  l)y  the  freciuent  association  of  pathological  changes 
in  the  various  organs  of  the  body  generally,  with  the  clinical  evidences 
of  achylia. 

Relation  of  Achylia  to  Other  Diseases. — In  the  following  table  the 
writer  has  tabulated  the  various  pathological  processes  that  occurred 
in  100  cases  of  achylia  in  his  private  practice: 

Achylia  in  Relation  to  Other  Diseases.     100  Cases. 

Negative  findings 34  cases 

Gastroptosis  alone 14  cases 

Gall-bladder  alone 16  cases 

Gastroptosis  and  gall-bladder 4  cases 

Arteriosclerosis  alone 6  cases 

Arteriosclerosis  and  gall-bladder 2  cases 

Cardiac  (all  compensated) 3  cases 

Gastroptosis  and  cardiac       . 2  cases 

Fatty  liver 1  case 

Hypertrophic  cirrhosis 2  cases 

Tuberculous  peritonitis 3  cases 

Pulmonary  tuberculosis 2  cases 

Chronic  appendicitis 5  cases 

Stone  in  ureter ,  1  case 

Dilated  esophagus  with  cardiospasm 1  case 

General  paresis 1  case 

Athyroidism 2  cases 

Postoperative  for  cancer  of  uterus  (after  six  years)    ...  1  case 

100  cases 

It  will  be  seen  that  the  associated  diseased  conditions  cover  a  very 
large  range,  and  are  so  scattered  that  with  two  exceptions  no  one  of 
them  is  observed  with  sufficient  frequency  with  achylia  to  have  any 
apparent  connection  with  this  disease.  For  example,  achylia  occurs 
in  6  per  cent,  of  all  patients  applying  for  treatment  and  in  but  8  per 
cent,  of  those  who  suffer  from  chronic  appendicitis.  Reference  to  the 
following  graphic  chart  will  show  that  there  is  no  apparent  connection 
between  the  two  conditions. 

Fig.  100 
Percentage  of  achylia  in  all  patients,  C  per  cent. 


Percentage  of  achylia  in  appendicitis,  S  per  cent. 


490 


ACHY  LI  A 


Association  of  Achylia  and  Gall-bladder  Disease. — Of  more  importance 
is  the  association  of  achylia  with  cholehthiasis  and  diseases  of  the 
gall-bladder.  Twenty-two  per  cent,  of  the  writer's  achylias  were  thus 
complicated. 

In  100  cases  of  gall-bladder  and  gallstone  disease  in  the  writer's 
practice  achylia  was  found  in  30  per  cent,  as  shown  in  the  following 
table : 

Acidities  in  100  Cases  of  Gall-bladder  Disease 

Hyperacidity 30  per  cent. 

Normal  acidity 30  per  cent. 

Subacidity 10  per  cent. 

Achylia 30  per  cent. 

The  probability  of  there  being  a  close  causal  relation  between  the 
two  diseases  is  shown  by  the  study  of  the  accompanying  diagrams: 

Fig.    101 


Percentage  of  achylia  in  all  patients,  6  per  cent. 


oi 


Percentage  of   achylia    in    those   with    gall-blaiklcr 
disease,  30  per  cent. 


JU,'! 

Percentage  of  gall-bladder  disease  in  all  patients,       J^,; 
3.6  per  cent.  I  f 


Percentage  of   gall-bladder   disease   in  achylia,  22  ^^^ 

per  cent.  XvWK^y',, .': 


In  the  first  table  it  will  be  seen  that  achylia  complicates  6  per  cent, 
of  all  gastro-intestinal  patients,  while  with  gall-bladder  disease  30  per 
cent,  of  patients  are  thus  affected.  Achylia  is  five  times  more  frequent 
in  those  with  gall-bladder  disease  than  in  those  who  are  free  from  this 
complaint. 

The  second  table  shows  that  the  patients  who  apply  to  the  specialist 
for  gastro-intestinal  disorders,  3.0  per  cent,  give  evidence  of  gall-})lad(ler 
infection  in  one  or  the  other  of  its  forms,  while  in  100  patients  with 
achylia,  22  per  cent,  suffer  also  from  gall-bladder  disease.  Infections 
of  the  gall-bladder  are  thas  six  times  as  frequent  in  achylia  as  in  those 
whose  gastric  secretions  are  normal.  An  example  of  a  not  unusual  clinical 
history  may  be  given  pointing  to  such  a  connection  between  the  two 
diseases: 

Mr.  W.  (t.  a.,  aged  forty-seven  years,  is  of  temperate  habits  and 
careful   in   the  choice  of    his   food,   which   he   masticates  thoroughly. 


NATURE  AND  PATHOLOGY  OF  Af'HYLIA  491 

Is  not  a  nervous  man  by  nature,  and  his  life  is  well  rej^ulated  and 
orderly.  He  has  never  suffered  from  any  abdominal  distress  until 
his  present  illness. 

Three  years  ago  he  began  to  suffer  from  recurrent  attacks  of  gallstone 
colic,  during  several  of  which  he  became  distinctly  jaundiced. 

Physical  Examination. — The  gall-bladder  is  palpable  and  distinctly 
tender.     There  is  well-marked  rigidity  both  of  the  right  costal  arch, 
and  of  the  upper  part  of  the  right  rectus  muscle.    Otherwise  his  exami- 
nation is  negative. 
Fasting  stomach,  empty. 

Test  breakfast,  50  c.c,  poorly  chymified,  of  dryish  consistency,  with 
scanty  quantities  of  mucus  enveloping  the  bread  fragments.  Total 
acidity  12.     Free  hydrochloric  acid  absent. 

In  many  cases  cholecystitis  is  directly  and  immediately  followed  by 
the  disappearance  of  hydrochloric  acid  from  the  gastric  juice. 
The  following  example  of  this  may  be  given : 

A  robust  athletic  young  man  consulted  the  WTiter  for  a  temporary 
indigestion,  and  at  this  time  the  test  breakfast  was  normal.  Two 
weeks  later  he  was  attacked  by  hepatic  colic,  the  stone  lodging  in  his 
common  duct.  Three  days  after  this  gallstone  attack  his  test  breakfast 
showed  achylia.  The  stone  was  subsequently  removed  surgically, 
but  although  his  recovery  was  perfect,  and  he  is  the  picture  of  athletic 
manhood,  eating  and  apparently  digesting  everything  with  impunity,  at 
no  time,  now  seven  years  since  the  attack,  has  the  gastric  juice  ever 
shown  the  presence  of  hydrochloric  acid  in  either  free  or  combined 
form. 

The  following  case  is  one  of  achylia  following  typhoid  infection  of 
the  gall-bladder: 

E.  C,  aged  thirty-five  years,  was  under  the  writer's  care  for  many 
years  suffering  from  gastroptosis  and  a  mild  degree  of  atony.  Examina- 
tion of  stomach  contents  was  repeatedly  made  during  this  time  and 
invariably  showed  normal  or  slightly  excessive  acidity.  In  July,  1909, 
the  patient  went  through  a  mild  typhoid,  complicated  by  pain  and  ten- 
derness referred  to  the  gall-bladder  region.  There  was  slight  rigidity 
of  the  upper  right  rectus  muscle.  These  symptoms  continued  oft'  and 
on  for  three  months  after  recovery  from  the  fever,  and  during  this 
time  and  since  then,  a  period  of  three  years,  an  absolute  achylia 
has  persisted.  This  sequence  of  typhoid  fever,  infection  of  the 
gall-bladder,  and  achylia  has  repeatedly  been  obser\ed  b}'  the 
writer. 

It  would  also  seem  that  achylia  of  those  past  middle  life  might  be 
explained  by  the  increasing  number  of  cases  of  cholelithiasis  and 
cholecystitis  during  these  years  as  M'ell  as  by  the  occurrence  of  the 


492  ACHY  LI  A 

pathological  changes  of  atrophy  previously  described — and  the  writer 
has  compiled  from  his  cases  the  following  tahle: 

Age  Relations  of  Achylia  and  Cholelithiasis. 
Of  patients  with  achylia  between  the  ages  of  40  and  50  years,  gall-bladder 

disease  was  present  in  27  per  cent. 
Of  patients  with  achylia  between  the  ages  of  50  and  60  years,  gall-bladder 

disease  was  present  in  20  per  cent. 
Of  patients  with  achylia  between  the  ages  of  60  and  70  years,  gall-bladder 

disease  was  present  in  47  per  cent. 

The  writer  believes  therefore  that  there  is  a  close  causal  relation  l)e- 
tween  gallstones  and  inflammation  of  the  gall-bladder  on  the  one  hand 
and  achylia  on  the  other.  These  former  conditions  often  run  a  course 
attended  by  such  insignificant  local  symptoms  and  physical  signs  that 
their  presence  is  unsuspected.  Were  we  able  to  ascertain  correctly 
the  condition  of  the  gall-bladder  in  all  of  our  cases  of  achylia  it  is  quite 
probable  that  many  cases  of  obscure  origin  might  be  explained  in  this 
way.  The  longer  we  watch  our  individual  cases  of  achylia  the  more 
often  do  we  find  attacks  of  gall-bladder  infection  appearing  from  time 
to  time  in  the  clinical  history.  Of  interest  in  this  connection  is  the 
following  history,  showing  latency  of  the  gall-bladder  lesion  until  long 
after  achylia  had  been  recognized. 

Mrs.  H.  T.,  aged  fifty-four  years. 

The  appendix  had  been  removed  eight  years  ago,  after  the  third 
attack  of  acute  inflammation. 

Three  years  ago  complained  of  indefinite  pains  in  the  upper  abdomen 
and  vague  symptoms  of  dyspepsia.  These  symptoms  soon  disappeared, 
returned  for  a  few  days  a  month  or  so  later,  since  which  time  she  has 
been  free  from  all  distress.  For  two  years  her  complaint  has  been  of 
diarrhea  in  attacks  lasting  for  several  weeks  at  a  time  quite  se\'erely, 
having  during  these  periods  four  or  five  loose  movements  limited  to  the 
morning  hours.  At  other  times  she  will  have  but  one  semiformecl 
movement  daily.  At  no  time  has  there  been  nausea,  v(miiting,  or  any 
epigastric  distress  whatever. 

Physical  /^.m/////;r///o//. ^Negative,  no  tenderness  over  gall-bladder 
region.    Gall-bladder  not  j)alpable.    No  dorsal  i)oint  of  tenderness. 

Fasting  stomach  empty. 

Test  breakfast,  50  c.c.  of  poorly  digested  bread  fragments,  admixed 
with  a  considerable  amount  of  mucus.  Total  acidity  10;  free  hydro- 
chloric acid  absent. 

Lab-zymogen  active  in  dilutions  of  1  to  10;  inactive  in  dilutions  of 
1  to  20;  lavage  in  the  fasting  state  brought  no  mucus.  Stool  examina- 
tion showed  a  mild  enteritis. 


NATURE  AND  I'ATIIOLOdY  OF  ACHY  LI  A  493 

The  case  was  considered  one  of  anacid  catarrhal  gastritis  and  was  so 
treated. 

Four  months  hiter  acute  empyema  of  the  gall-bladder  appeared, 
with  purulent  infection  of  the  right  pleural  cavity,  from  which  she  died. 
It  is  probable  that  old  standing  cholecystitis  with  gallstones  had  been 
present,  causing  the  symptoms  of  which  she  complained  three  years 
before  her  death  and  w^hich  ran  a  latent  course  and  without  physical 
signs  during  the  time  in  which  she  was  under  observation,  until  sud- 
denly symptoms  of  severe  gall-bladder  infection  appeared  and  caused 
her  death. 

It  is  interesting  to  note  that  improvement  or  cure  of  the  gall- 
bladder disease  is  not,  as  a  rule,  followed  by  a  return  of  the  gastric 
secretion. 

It  is  possible  that  achylia  may  result  from  derangements  of  the 
secretion  of  the  internal  glandular  structures  of  the  body.  Of  170 
cases  of  achylia  there  were  three  patients  in  whom  symptoms  of 
hypothyroidism  were  present.  In  all  of  these  rapid  improvement 
in  general  condition  followed  th^Toid  feeding,  although  in  none  was 
this  improvement  followed  by  the  return  of  gastric  juice.  It  is  to 
be  hoped  with  increasing  knowledge  of  internal  secretions,  light  may 
be  thrown  upon  a  possible  relationship  of  these  derangements  with 
achylia. 

Association  of  Achylia  and  Gastroptosis. — It  is  apparently  significant 
that  gastroptosis  should  accompany  20  per  cent,  of  achylias,  either 
alone  or  associated  with  cardiac  or  gall-bladder  disease.  Many 
authorities  in  their  description  of  gastroptosis  consider  that  achylia 
in  that  condition  is  exceedingly  frequent. 

Steel  and  Francine  consider  that  in  gastroptosis,  absence  or  diminu- 
tion of  the  free  hydrochloric  acid  is  the  rule— Brown,  in  Osier's  Practice 
of  Medicine  states  that  hydrochloric  acid  was  absent  in  most  of  the 
patients  with  gastroptosis  accompanied  by  high  grades  of  dilatation. 
The  writer  cannot  believe  that  these  statements  are  correct,  nor  can  he 
see  that  there  is  any  connection  whatever  between  achylia  and  gastrop- 
tosis, but  considers  that  their  association  is  entirely  accidental  and 
is  due  to  the  fact  that  both  diseases  occur  with  such  frequency  that  in 
a  certain  number  of  patients  they  are  unfortunately  liable  to  occur  at 
the  same  time. 

Gastroptosis  occurs  in  IS  j^er  cent,  of  all  patients  with  (/astro-intestinal 
symptoms  and  in  20  per  cent,  of  those  with  achylia — a  difference  in  fre- 
quency too  small  to  be  of  importance. 

Achylia  occurs  in  6  per  cent,  of  all  patients  with  gastro-intestinal 
symptoms,  and  in  but  between  9  and  10  per  cent,  of  those  with  gastrop- 
tosis, again  a  difference  in  frequency  that  may  be  considered  negligible. 


494 


ACHY  LI  A 


These  percentages  ma}'  be  graphically  shown  by  the  accompanying 
diagrams : 


Fig.   102 


Percentage  of  achylia  in  all  patients,  6  per  cent. 


6'} 


Percentage  of  achylia  in  gastroptosis  patients,  9.8 
per  cent. 


m^ 


Percentage 
cent. 


of  gastroptosis  in  all  patients,  18  per       ,   in^ 


Percentage  of  gastropto.sis  in  achylia,  20  per  cent. 


Symptoms. — Latent  Course. — In  the  majority  of  cases  of  achylia, 
gastric  symptoms  are  absent,  or  if  present  are  due  to  associated  condi- 
tions which  may  coexist  in  the  same  patient,  quite  independently  of 
the  achylia  itself,  and  no  suspicion  of  its  presence  is  entertained  until 
chemical  examination  of  the  gastric  contents  is  made. 

The  patients  do  not,  as  a  rule,  look  or  act  differently  from  those  whose 
digestion  is  normal  They  are  not  anemic  nor  neurasthenic,  neither  are 
they  undernourished.  They  live  wisely,  eat  all  kinds  of  food  with 
relish  and  without  the  least  distress,  nor  do  they  give  in  their  clinical 
history  any  complaint  of  having  any  indigestion  whatever.  They 
simply  have  no  gastric  juice,  and  they  go  for  months  or  years  without 
its  return,  apparently  none  the  worse  for  its  absence.  There  is  nothing 
in  their  history,  mode  of  life,  or  physical  examination  to  throw  any  light 
upon  the  nature  of  the  process.  We  find  by  accident  that  they  haAc 
achylia — more  than  this  we  do  not  know. 

Such  a  clinical  history  may  not  occasion  surprise  if  elicited  from  a 
patient  in  whom  we  su.spect  a  functional  origin  for  the  achylia,  but  it  is 
more  remarkable  Avhen  well-marked  structural  change  in  the  mucous 
membrane  of  the  stomach  is  apparently  the  cause  for  the  complaint.  In 
these  cases  of  apparent  organic  origin  the  course  throughout  may  be 
latent,  or  there  may  be  the  history  of  previous  severe  indigestion  that 
has  gradually  lessened  so  that  symptoms  have  become  finally  quiescent 
and  the  patient  presumably  free  from  all  gastric  error.  The  following 
case  may  be  cited  as  an  example  of  achylia  without  symptoms,  appar- 
ently due  to  structural  changes  following  gastro-enteritis  from  cholera 
infection: 

W.  A.  I),  was  .seen  in  1S!)(S  with  the  following  history:  lie  suffered 
in  1848  from  a  severe  attack  of  A.siatic  cholera  that  was  e])idemic  in 


SYMPTOMS  OF  ACHY  LI  A  495 

New  Orleans  during  that  year.  His  convalescence  was  retarded  by 
persistent  vomiting  and  diarrhea,  which  continued  oft'  and  on  for  sexeral 
months.  Complete  recovery  finally  ensued,  although  ever  since  then 
he  has  been  subject  to  slight  attacks  of  diarrhea  during  the  first  onset 
of  cold  weather  or  after  glaring  dietetic  errors.  Aside  from  these  tran- 
sient indispositions  and  a  winter  cough  the  result  of  chronic  bron- 
chitis with  emphysema,  he  has  remained. well  and  able  to  eat  what  has 
pleased  him,  without  discomfort. 

When  seen  in  1898  he  was  seventy-four  years  of  age  and  was  found 
to  have  achylia.  For  the  past  twelve  years  this  has  continued,  and  he  is 
at  the  present  time  a  hale  and  hearty  old  gentleman,  eighty-nine  years 
of  age,  who  is  free  from  all  digestive  trouble  and  who  enjoys  life  with 
keen  relish. 

The  absence  of  gastric  symptoms  is  due  to  two  causes: 

In  uncomplicated  achylia  motor  errors  do  not  occur.  The  stomach 
shows  normal,  or  as  many  believe,  increased  motor  power,  so  that  its 
contents  are  passed  into  the  intestine  within  normal  time  limits  to  say 
the  least.  Stagnation  and  fermentation  of  food  do  not  occur.  Flatu- 
lence is  not  a  symptom  of  the  disease.  Achylia  with  gastric  flatulency 
regularl}^  implies  the  existence  of  some  complicating  motor  error. 
Achylia  with  stagnation  suggests  malignancy  and  justifies  explora- 
tion. 

Intestinal  digestion  is  naturally  capable  of  doing  all  the  work  required 
for  the  maintenance  of  health  and  nutrition,  so  that  gastric  digestion 
is  in  a  way  superfluous.  Should,  however,  bowel  disturbances  occur, 
this  compensatory  digestion  is  rendered  imperfect,  malnutrition  and 
diarrhea  are  apt  to  occur.  The  lack  of  intestinal  digestion  is  never 
in  achylia  sufficient  in  itself  to  induce  progressive  loss  of  flesh  to  any 
great  extent,  unless  there  be  diarrhea — the  loss  of  weight  when  it  occurs, 
is  attributable  rather  to  this  latter  condition  and  proportionate  to  its 
severity  than  to  insufficient  compensatory  digestion  within  the  intestinal 
tract.  Progressive  loss  of  flesh  and  strength  that  is  not  commensurate 
with  the  severity  and  chronicity  of  the  diarrhea  should  arouse  the 
suspicion  that  more  than  simple  achylia  is  present. 

Gastric  Symptoms. — Gastric  symptoms  are  but  rarely  present  in 
uncomplicated  achylia. 

In  a  certain  number  of  patients,  3  per  cent,  of  the  writer's  cases, 
"heart-burn"  and  "acidity"  occasioned  considerable  distress.  The 
patient  complains  that  about  one  hour  after  he  takes  his  food,  he  is 
annoyed  by  a  burning  sensation  in  the  stomach,  relieved  by  alkalies  or 
by  eating,  and  his  description  is  the  same  as  that  given  by  those  whose 
gastric  contents  at  this  time  are  excessively  acid,  so  that  there  is  no 
way  by  which  a  differential  diagnosis  may  be  made  except  by  means  of 


496  ACHY  LI  A 

the  stomach-tube.  Withdrawal  of  the  gastric  contents  at  the  time  at 
which  this  distress  is  present,  usually  shows  that  the  gastric  contents 
are  free  from  all  acidity  and  are  dryish  and  of  a  squeezed-out  appearance. 
This  abnormal  dryness  of  the  contents  of  the  stomach  is  probabl.y 
the  reason  for  the  subjective  distress,  a  supposition  that  is  further 
corroborated  by  the  fact  that  drinking  a  glass  of  plain  water  will 
relieve  as  completely  as  if  a  similar  quantity  of  alkaline  fluid  had 
been  taken.  The  following  is  the  history  of  such  a  case  of  spurious 
hyperacidity  occurring  in  achylia. 

H.  C,  aged  thirty-five  years,  was  well  and  without  digestive  ailments 
or  distress  of  any  kind  until  four  years  ago.  At  that  time  without 
any  apparent  cause  he  began  to  suffer  from  a  burning  pain  in  the 
stomach  appearing  one  or  two  hours  after  meals,  intensified  by  mental 
excitement  or  physical  fatigue.  Eating  and  drinking  soda  in  Vichy 
regularly  relieve  his  distress.  Of  late  he  has  complained  of  a  moder- 
ate amount  of  gas  in  his  stomach.  He  has  remained  physically  well. 
Chief  complaint  is  heart-burn. 

Physical  examination  shows  a  healthy  looking  man.  The  lower 
curvature  of  the  stomach  lies  4  cm.  below  the  navel  and  is  moderately 
atonic. 

Fasting  stomach  empty. 

Test  breakfast,  dry  achylia;  total  acidity  6.     Zymogen  active,  xIf- 

In  this  case  the  flatulence  of  which  he  complained  could  be  probably 
attributed  to  his  gastroptosis  and  atony,  rather  than  to  his  achylia. 

Nausea  and  vomiting  occur  so  rarely  in  achylia,  that  their  presence 
suggests  the  possibility  of  some  complication  to  which  they  may  be  due. 
Persistent  vomiting  suggests  malignancy,  occasional  attacks  of  vomiting 
with  pain  suggest  gall-bladder  complications. 

Intestinal  Symptoms. — The  symptoms  due  to  achylia  are  chiefly 
intestinal,  and  consist  of  (1)  diarrhea;  (2)  intestinal  flatulence  and 
discomfort;  (3)  intestinal  toxemia. 

Diarrhea. — Diarrhea  is  the  most  frequent  symptom  of  achylia,  and 
was  present  in  34  per  cent,  of  the  writer's  cases.  Strauss  reports  that 
it  occurred  in  36  per  cent,  of  the  achylias  that  he  has  seen. 

In  many  cases,  merely  a  tendency  to  diarrhea  exists.  From  time 
to  time  attacks  occur  described  by  the  patients  as  ordinary  "summer 
complaint,"  although  they  are  usually  more  prolonged  and  show  a 
greater  tendency  to  recur.  These  outbreaks  are  more  frequent  in 
summer  than  in  winter;  they  may  follow  a  definite  dietetic  error  or 
there  may  be  no  apparent  reason  for  them  that  we  can  discover. 

In  other  instances  the  patients  will  go  steadily  along,  having  one  or 
two  loose  mo\('nu'nts  before  or  after  breakfast  — rarely  being  annoyed 
during  the  (\i\y.    There  may  be  abdominal  discomfort  and  rumbling 


SYMPTOMS  OF  ACHY  LI  A  497 

preceding  the  evacuation,  and  considerable  flatus  may  be  expelled, 
but  pain  in  these  milder  cases  does  not  occur. 

In  more  severe  instances  the  diarrheal  movements  become  more 
frequent  and  materially  interfere  with  the  nutrition  and  general  health 
of  the  patient.  The  diarrhea  occurs  with  its  greatest  intensity  during 
the  early  morning  hours,  and  usually  becomes  less  marked  or  even  ceases 
after  the  early  part  of  the  forenoon.  It  would  seem  as  if  food  taken 
during  the  day  fermented  and  irritated  the  bowel  during  the  night, 
and  was  evacuated  in  the  early  morning.  This  predilection  for  the  early 
morning  hours  is  characteristic  of  diarrhea  that  owes  its  origin  to  dis- 
turbances in  gastric  chemistry,  and  is  seen  both  in  cases  of  hyperacidity, 
and  in  cases  of  achylia,  although  it  is  much  more  frequent  in  the  latter 
condition. 

Examination  of  the  stools  is  often  quite  characteristic.  In  the  milder 
cases  we  may  find  only  a  few  undigested  meat  fibers  and  a  great  excess 
of  connective  tissue  in  threads  and  flakes  occasionally  appearing  as 
a  fine  network  throughout  a  stool  that  may  otherwise  appear  normal. 
The  presence  of  connective  tissue  in  excess  especially  when  it  appears 
as  a  macroscopic  residue,  clearly  shows  a  lack  of  gastric  secretion,  for 
we  know  that  connective  tissue  unless  thoroughly  cooked  and  softened, 
is  digested  only  or  chiefly  in  the  stomach. 

In  cases  of  greater  severity  the  stools  are  large  and  liquid  and  usually 
quite  offensive  by  an  excess  of  fatty  acids  and  soaps.  Undigested  meat 
fibers  are  usually  present  in  considerable  number  and  undigested  con- 
nective tissue  is  apt  to  be  sufficiently  abundant  to  form  a  residue  that 
is  evident  to  the  naked  eye. 

In  a  certain  number  of  these  stools  evidence  may  be  present  of  a 
catarrhal  inflammation  of  the  small  intestines. 

Enteritis  may  be  due  to  the  irritation  of  the  mucous  membrane  of 
the  small  bowel  by  undigested  food,  or  may  arise  from  excessive  bac- 
terial growth  that  is  in  turn  due  to  the  presence  of  an  excess  of  undigested 
proteid  matter  within  the  lumen  of  the  bowel.  The  mechanical  irrita- 
tion caused  by  the  undigested  food  entering  the  bowel  may  also  be 
considered  quite  a  potent  cause. 

The  writer  has  found  that  in  the  cases  of  diarrhea  that  occur  with 
achylia,  evidences  of  enteric  catarrh  are  found  in  the  stools  of  three- 
quarters  of  the  number.  Mucus  is  present,  freely  and  intimately 
admixed  with  the  more  solid  portions  of  fecal  matter,  indicating  that 
its  origin  is  above  the  large  intestine,  although  we  are  unable  in  many 
cases  to  state  which  portion  of  the  small  intestine  is  the  more  involved. 
If  under  the  microscope  small  clusters  of  undigested  starch  granules 
are  surrounded  by  a  capsule  of  fine  mucus,  the  catarrhal  process  prob- 
ably involves  the  upper  and  midportions  of  the  jejunum.  INIucus  with 
32 


498  ACHY  LI  A 

leukocytes  and  intestinal  epithelium  that  are  intimately  admixed  also 
indicates  catarrhal  processes  in  the  small  bowel. 

To  determine  the  probable  origin  of  intestinal  mucus  Krauss  recom- 
mends the  following  method  of  examination. 

A  fecal  smear  is  stained  with  a  1  per  cent,  solution  of  alizarin  sodium 
sulphonate.  Mucus  that  is  normally  present  in  the  stools,  the 
"cohesion  mucus"  as  it  was  termed  by  Nothnagel,  is  evidenced  by  the 
appearance  of  small  flakes  and  scales  tinged  faintly  yellow.  The  farther 
the  mucus  has  to  travel  or,  in  other  words,  the  higher  is  its  origin  within 
the  bowel  the  more  faintly  it  is  stained.  Bright  large  red  flakes  have 
their  source  in  the  lower  part  of  the  large  intestine — mucus  from  the 
smaller  intestine  is  stained  lightly  yellow,  and  the  nearer  the  source 
of  the  mucus  is  to  the  duodenum  the  paler  is  the  tint. 

In  other  cases  there  are  no  evidences  in  the  stools  of  any  catarrh 
of  the  intestine  that  we  can  discover — the  evacuations  are  pea  soup 
in  consistency  and  their  liquid  character  seems  chiefly  due  to  increased 
intestinal  peristalsis.  It  is  in  these  cases  that  small  doses  of  bromides 
are  followed  by  such  brilliant  results. 

Evidences  of  colitis  in  the  stools,  such  as  the  presence  of  large  masses 
of  mucus  not  intimately  admixed  with  the  fecal  matter  but  lying  free 
or  coating  large  fecal  masses,  are  not  usually  seen  in  achylia  unless 
from  some  intercurrent  complication. 

Occult  bleeding  does  not  occur  in  achylia.  Repeated  positive  blood 
reactions  in  the  stools  suggest  the  possibility  of  malignancy. 

Abdominal  Distress  and  Distention. — Abdominal  distress  and  dis- 
tention occur  in  many  of  the  cases,  usually  but  not  necessarily  associated 
with  diarrhea.  The  discomfort  is  usually  more  or  less  constant  through- 
out the  day,  or  may  be  limited  to  the  morning  hours.  So  frequently 
do  the  symptoms  of  intestinal  indigestion  owe  their  origin  to  changes 
in  gastric  secretions,  that  in  every  case  presenting  these  symptoms 
examination  of  the  gastric  contents  should  be  made. 

Intestinal  Toxemia. — Symptoms  of  intestinal  toxemia  are  present  in 
a  large  number  of  patients  with  achylia,  although  not  relatively  as 
frequent  as  in  hyperacidity,  nor  are  they  as  common  in  achylia  without 
atony  as  in  the  cases  in  which  this  complication  is  present. 

There  may  be  recurring  attacks  of  "biliousness,"  of  headaches  or 
of  mental  depression.  There  may  be  various  forms  of  skin  diseases 
dependent  for  their  origin  u])()n  intestinal  toxemia,  urticaria  being 
by  far  the  most  common.  These  symptoms  of  intestinal  poisoning 
are  not  characteristic  of  achylia,  any  more  than  they  are  of  a  great 
variety  of  gastric  and  intestinal  disorders. 

An  interesting  history  is  the  following: 

Mrs.  H.  II.  B.,  aged  fifty  years. 

Twenty-one  years  ago  a  pehic  abscess,  thought  to  be  perityphlitic, 


SYMPTOMS  OF  ACHY  LI  A  499 

ruptured  into  the  bowel.  This  was  followed  by  complete  recovery,  and 
she  remained  perfectly  well  with  the  exception  of  attacks  of  what  was 
thought  to  be  (gallstone  colic  twenty  years  ago  and  again  six  years  ago. 

For  the  past  two  years  she  has  suffered  indescribable  torment  from 
chronic  urticaria,  the  body  never  for  a  moment  being  free  from  the 
eruption,  so  that  she  has  been  unable  to  sleep  and  has  become  both 
physically  and  nervously  exhausted.  She  has  been  under  constant 
treatment  by  eminent  specialists,  both  by  external  aj)})li('ations  and  by 
a  great  variety  of  internal  medication. 

She  gives  no  history  of  any  past  or  present  gastric  symptoms  of  any 
kind  whatever.  Her  bowels  move  loosely  every  day  from  laxative 
medicine  that  has  been  ordered  for  her. 

Physical  Examination. — Patient  much  exhausted  from  constant  itch- 
ing and  lack  of  sleep.  Surface  of  the  body  covered  by  extensive 
urticarial  eruption.  Gall-bladder  neither  tender  nor  palpable.  Position 
and  size  of  stomach  normal — no  evidences  of  atony.  Examination 
otherwise  negative. 

Fasting  stomach,  normal. 

Test  breakfast  shows  dry  achylia;  total  acidity,  6. 

Lab-zymogen,  negative  ^,  faintly  positive  iV- 

Stool  examination  shows  connective  tissue  present  to  a  macroscopical 
degree.  Fine  mucus  intimately  admixed.  Slight  excess  of  fatty  acids 
and  soaps — odor  somewhat  putrefactive. 

Patient  was  placed  on  an  achylia  diet,  and  ordered  oxyntin  by  mouth, 
small  doses  of  strontium  bromide,  and  intestinal  irrigations.  The 
eruption  ceased  within  a  few  da}'S  and  for  the  past  six  years  there  has 
been  no  return.  During  the  last  year  she  has  successfully  been  operated 
on  for  acute  impaction  of  a  stone  in  the  common  duct.  The  association 
of  achylia  with  diseases  of  the  gall-bladder  and  gallstones  is  here  quite 
clearly  indicated. 

Achylia  with  Comphcations. — Achylia  is  so  often  accompanied  in  its 
course  by  lesions  of  the  gall-bladder  and  by  gastroptosis  that  special 
description  should  be  given  of  the  symptoms  that  arise  from  such 
combinations.  This  seems  to  the  writer  quite  important,  as  many  symp- 
toms due  entirely  to  these  coexisting  disorders  are  attributed  to  the 
achylia  whereas  in  fact  they  owe  their  existence  entirely'  to  the  asso- 
ciated disorder.  If  the  cases  of  achylia  are  divided  into  three  groups, 
one  of  achylia,  pure  and  simple,  one  of  achylia  with  lesions  of  the  gall- 
bladder with  or  without  symptoms  of  gallstones,  and  one  in  which  achylia 
occurs  with  gastroptosis,  it  will  be  readily  seen  that  many  symptoms 
ordinarily  considered  to  be  the  result  of  lack  of  gastric  secretion  are 
present  only  in  the  groups  which  include  the  complicating  lesions. 
It  is  not  in  achylia  alone  that  we  may  apply  this  method  of  studying 


500  ACHY  LI  A 

our  cases — the  more  we  sort  out  symptoms  of  the  diseased  condition 
or  deranged  function  we  are  investigating  from  the  symptoms  of  other 
diseased  conditions  or  deranged  functions  that  may  coexist,  either 
directly,  or  indirectly  dependent  or  entirely  independent  of  each 
other,  the  simpler  and  the  less  confused  becomes  our  knowledge  of 
the  symptoms   of  disease. 

Gall-bladder  and  Gallstone  Gomplication.  —  Gall-bladder  or 
gallstone  complications  occur  in  22  per  cent,  of  all  achylia,  and  add 
their  symptoms  to  those  of  the  latter  disease.  It  has  been  seen  that  in 
achylia  the  chief  symptoms  are  intestinal  and  that  gastric  symptoms  are 
insignificant  and  usually  absent.  Gall-bladder  complications  (and  this 
term  is  used  by  the  writer  to  include  all  forms  of  gall-bladder  infections 
and  inflammations  with  or  without  the  formation  or  evidences  of  the 
presence  of  stones)  usually  give  well-marked  gastric  symptoms,  while 
not  interfering  in  the  slightest  with  any  of  the  functions  of  the  intestine. 
Cholecystitis  may  well  be  suspected  in  every  case  of  achylia  that  is 
attended  by  gastric  symptoms. 

Pain  is  a  symptom  that  does  not  occur  in  uncomplicated  achylia,  but 
is  frequently  present  in  the  gall-bladder  cases.  It  may  be  paroxysmal 
and  lancinating,  it  may  be  dull,  boring  or  aching,  occurring  usually 
independently  of  the  time  of  taking  food,  although  in  some  cases  a  defi- 
nite and  orderly  sequence  of  time  may  be  observed.  At  other  times 
the  pain  is  cramp-like — a  pain  that  is  always  suggestive  of  biliary 
disease.  Epigastric  pain  in  achylia  should  suggest  gall-bladder  disease, 
chronic  appendicitis,  arteriosclerosis,  or  malignancy. 

Nausea  and  vomiting  may  occur  from  time  to  time.  The  nausea  in 
these  cases  is  usually  mild  in  degree,  and  does  not  usually  prevent 
the  patient  from  a  full  enjoyment  of  his  meals,  after  he  has  once  sat 
down  to  the  table.  Vomiting  may  be  associated  with  attacks  of  epigas- 
tric pain  or  may  occur  independently.    It  is  quite  erratic  in  its  type. 

Sudden  attacks  of  gaseous  distention  of  the  stomach  may  occur.  The 
raising  of  brackish  or  bitter-tasting  fluid  is  not  infrequentl}"  observed. 

The  following  example  of  achylia  thus  complicated  may  be  given. 

Mrs.  W.,  aged  forty-two  years,  admitted  April  30,  1909,  with  the 
following  history. 

Patient  has  always  been  self-indulgent  and  reluctant  to  take  exercise. 
Her  diet  has  always  been  injudicious,  and  during  the  past  few  years 
she  has  grown  quite  stout. 

Her  digestion  gave  her  no  trouble  until  three  years  ago,  when  she 
began  to  comj)lain  of  sudden  attacks  of  painful  distention  of  the  stomach, 
for  which  she  would  take  a  great  variety  of  carminatives  and  from 
which  she  would  after  a  few  hours  obtain  relief  by  the  raising  of  wind 
in  great  (|uantities.    After  eating  she  would  often  feel  as  if  "there  was 


SYMPTOMS  OF  ACHY  LI  A  501 

a  ^reat  hole  in  her  stomach"  cjoite  uulepcndent  of  tlie  quality  or  (|uaii- 
tity  of  her  food.  From  time  to  time  she  suffered  from  pain  in  the  epi- 
gastrium of  a  dull  aehiufj  character,  coming  "at  any  time"  and  "by 
spells"  often  accompanied  by  nausea  and  by  vomiting  which  afforded 
no  relief  to  her  distress.  At  other  times  she  would  go  for  weeks  eating 
everything  without  any  discomfort  whate\er.  For  the  past  three  years 
she  has  had  morning  diarrhea  during  the  summer  months  without 
intermission,  while  during  the  cooler  part  of  the  year  she  has  suffered 
from  only  occasional  outbreaks  lasting  from  a  few  days  to  several  weeks 
at  a  time. 

Three  years  ago,  at  the  onset  of  her  present  illness,  a  test  breakfast 
disclosed  achylia. 

Phy.s-ical  Examination. — Large,  stout,  healthy  looking  woman. 

Lower  border  of  the  liver  cannot  be  determined  owing  to  the 
thickness  of  the  abdominal  wall. 

Gall-bladder  not  palpable,  but  deep  pressure  over  its  area  elicits 
exquisite  pain,  which  runs  through  to  the  back. 

Test  breakfast  shows  dry  achylia. 

Stool  examinations  show  characteristic  findings  of  enteric  catarrh. 

Two  months  later  there  occurred  a  typical  attack  of  acute  chole- 
cystitis, with  pain,  tenderness,  fever,  nausea,  and  vomiting,  together 
with  well-marked  rigidity  of  the  head  of  the  right  rectus  muscle. 

Li  this  case  the  only  symptom  of  achylia  was  the  diarrhea ;  the  acute 
gaseous  distentions,  pain,  nausea,  and  vomiting  w^ere  quite  characteristic 
of  chronic  cholecystitis,  probably  with  the  formation  of  gallstones. 

Gastroptosi.s  Complications.  —  Gastroptosis  complicates  20  per 
cent,  of  the  cases  of  achylia,  although  it  has  been  shown  that  the  occur- 
rence of  these  two  conditions  is  independent  of  each  other.  The  only 
symptom  that  is  added  by  the  achylia  to  those  due  to  the  gastroptosis 
is  diarrhea,  although  this  is  less  frequently  observed  than  in  the  cases 
in  which  achylia  occurs  alone. 

In  achylia  without  diarrhea  no  symptoms  whate\'er  are  added  to 
those  of  the  gastroptosis.  Loss  of  flesh  and  of  strength  that  occur 
in  many  cases  of  achylia  that  are  not  the  result  of  diarrhea  may  be 
explained  by  the  existence  of  a  coexisting  gastroptosis  and  atony, 
otherwise  we  should  be  suspicious  of  malignancy.  The  two  following 
examples  of  achylia  with  associated  gastroptosis  may  be  given: 

Achylia  with  Gastroptosis,  Symptoms  Entirely  Those  of  Gastroptosis. — 
Mrs.  W.,  aged  forty-five  years,  was  well  until  after  her  husband's 
death  fifteen  years  ago,  she  was  obliged  to  support  herself  by  giving 
music  lessons.  She  became  very  nervous  and  overworked,  and  soon 
developed  the  symptoms  of  her  present  complaint,  which  have  con- 
tinued with  more  or  less  severity  ever  since,  and  there  is  always  more  or 


502  ACHY  LI  A 

less  distress  from  flatulency.  She  is  distended  and  bloated,  although  it 
is  with  difficulty  that  she  can  either  raise  or  pass  wind  in  sufficient 
quantity  to  relieve  her  distress. 

For  the  most  part  she  has  lost  her  appetite  altogether;  at  times  she 
may  start  her  meal  with  relish,  which,  however,  is  replaced  by  a  sense 
of  satiety  after  she  has  eaten  of  a  small  quantity. 

She  has  lost  progressively  in  flesh  and  strength  and  has  become 
markedly  neurasthenic.  Her  bowels  are  constipated  and  contain  long 
strings  of  mucus. 

Physical  Examination. — Patient  is  a  slight  delicate-looking  woman, 
much  under  weight;  thorax  long  and  narrow;  costal  angle  forty-fi^'e 
degrees. 

Lower  l^order  of  stomach  S  centimeters  below  the  navel,  splashing 
readily  to  this  point.  Gastric  tympany  extends  S  centimeters  to  the 
right  of  navel.  Right  kidney  palpable  two-thirds  of  its  extent.  The 
lower  border  of  the  liver  is  one  inch  below  the  costal  arch  in  the 
mammary  line;  its  edge  feels  normal.  (Tall-bladder  tenderness  not 
elicited.     Marked  coloptosis  present. 

Fasting  stomach,  negative. 

Test  breakfast:   15  cubic  centimeters;  dry  achylia;  total  acidity  (>. 

Lab-zymogen,  positive  1:180,  negative  1:1(30. 

Achylia  with  Gastroptosis. — Diarrhea  the  only  syniptoni  due  to  achylia. 
M.  P.  S.,  aged  fifty  years,  has  complained  for  the  past  fifteen  years 
of  morning  diarrhea,  which  with  but  few  exceptions  has  been  constant. 
During  this  time  she  has  lost  in  flesh  and  strength,  and  has  complained 
of  bloating  of  the  stomach  no  matter  what  she  eats.  She  has  grown 
exceedingly  nervous  and  camiot  sleep,  partly  on  account  of  her  nervous 
condition  and  partly  because  of  the  distress.  She  has  abdominal  pain 
from  time  to  time,  followed  by  long  strings  of  mucus  in  the  stools. 

Physical  E.vanti nation. — Tall  thin  woman,  undernourished  and  slightly 
anemic. 

Costal  angle  50  degrees;  general  characteristics  of  enteroptotic 
habitus  present.  Lower  border  of  stomach  10  centimeters  })el()W  navel. 
Right  ki(lne\-  freely  i)alpable.     Marked  coloptosis  is  present. 

Fasting  stomach,  negative. 

Test  l)reakfast:  20  cubic  centimeters;  dry  achylia;  total  acidity  (i. 

Lab-zymogen,  1 :18()  positive. 

Lavage  of  the  fasting  stomach,  negative. 

Stools  show  the  characteristic  findings  of  a  mild  enteric  catarrh, 
containing  finely  disseminated  mucus;  large  masses  of  umligested 
connective  tissue  and  many  muscle  fibers;  (juite  ofl'ensixe  from  excess 
of  fatty  acids  and  soaps.  Strings  of  mucus  are  present,  characteristic 
of  membranous  colitis. 


DIAGNOSfS  OF  ACflYL/A 


503 


Fig.   103 


Diagnosis. — Gastric  Analysis. — The  fasting  stomach  is  almost  regu- 
arly  empty,  although  occasionally  there  may  be  aspirated  small  quan- 
tities of  mucus  or  of  bile-stained  fluid 
which  evidently  enters  the  stomach 
from  the  straining  efi'orts  due  to  the 
passage  of  the  tube.  Food  stagna- 
tion and  bacterial  overgrowth  are 
regularly  absent,  as  motor  errors  do 
not  exist  in  non-malignant  achylia. 
The  absence  of  stagnation  in  any 
form  whatever  is  of  prime  importance 
in  differentiating  simple  achylia  from 
cancer.  Should  any  suspicion  of 
malignancy  exist   repeated   examina- 


Fig.  104 

wK^^^^^^ 

■^ 

8^,,.    . ■!^'*'^*^*.^^ 

^^3^^^ 

H^  ."         •" — ;"~ — "  - 

^""wff 

I 

■ 

'    '•%■ 

^^H '  ^  ^-^-^ 

.i— « 

^^^^^H   - 

'  "m^^^M 

^^^^^^^1  y^i;,j^^^^/-;--  '^^^A .- 

J 

Test  breakfast  in  achylia.     (Dry  form.)  A  common  form  of  test  breakfast  in  achylia.    A  small 

Notice   scanty  return   of   undigested   food-  amount  of  undigested  breadstuffs  is  obtained,  floating 

stuffs  in  lumps  enveloped  in  sticky  mucus  in  a  scanty  quantity  of  clear  fluid, 
adhering  to  the  side  of  the  bottle. 


tions  should  be  made,  so  that  a  conclusion  may  be  arrived  at  without 
unnecessary  delay.    Achylia  with  stagnation  justifies  exploration. 

Trichomonas,  megalostomas,  and  various  other  forms  of  infusoria 
may  exceptionally  be  present.  These  infusoria  are  not  suggestive  of 
cancer  as  was  at  one  time  supposed,  as  we  now  know  that  their  breeding 
place  is  about  the  roots  of  carious  teeth  and  that  they  may  exist  in 
the  fasting  stomach  after  they  have  been  swallowed,  in  any  case  in 
which  acid  secretions  in  the  stomach  are  lacking. 

Test  breakfast  may  appear  in  any  one  of  three  forms.  The  first  and 
the  most  usual  form  is  known  as  the  dry  achylia.  The  quantity  extracted 
is  small,  and  consists  of  bread  fragments  that  look  exactlv  as  if  thev 


504 


ACHY  LI  A 


had  l)eeii  chewed  and  spat  out.  These  Httle  fragments  may  be  mixed 
with  a  small  amount  of  mucus  and  saliva.  Often  only  a  teaspoonful 
of  such  material  can  be  extracted,  the  small  quantity  being  due  rather 


Fig.   105 


Test  breakfast  in  achylia.  The  undigested  breadstuffs  settle  in  a  flocculent  mass.  The  supernatant 
fluid  is  composed  of  verj'  thin  mucus  and  fluid  of  a  viscid  consistency,  but  not  thick  enough  to  be 
raised  on  a  hook. 

to  the  difficulty  of  getting  such  a  dry  material  through  the  stomach- 
tube  than  to  any  hypermotility  of  the  stomach,  because  if  we  wash 
out  the  stomach  after  withdrawing  such  a  small  proportion  of  the 

Fig.  100 


Test  breakfast  of  chronic  anacid  gastritis.    The  undigested  breadstuffs  are  seen  floating 

in  thin  mucvis. 

test  breakfast  we  will  find  the  balance  in  the  wash-water.     This  form 
occurred  in  126  out  of  176  cases  of  achylia  in  the  writer's  series. 
The  second  form  is  the  "wet  varietw"     The  test  breakfast  consists 


DIAGXOSrS  OF  ACHY  LI  A 


505 


of  a  Iar<j;c  quantity,  from  30  c.c.  to  200  c.c,  of  unditijested  hreaclstufls, 
floating  in  a  sea  of  mucus.  This  is  evidently  a  catarrhal  form,  and  yet 
in  the  majority  of  cases  the  stomach  secretes  mucus  only  in  the  digesting 
state,  as  is  shown  by  the  fact  that  washing  of  the  fasting  stomach  does 
not  bring  out  the  least  particle  of  mucus.  This  form  occurred  in  39 
out  of  176  cases  of  achylia. 

The  third  variety  is  that  of  an  apparently  normal  well  chymified 
test  breakfast,  although  on  close  examination  it  has  not  the  puree 
consistency  of  the  normal,  but  is  of  a  slightly  more  granular  appearance. 
This  form  occurred  in  11  out  of  170  cases  of  achvlia. 


Fig.  107 


Test  breakfast  in  achylia.  A  rare  form  in  which  the  appearance  is  practically  normal 
and  well  chymified. 

The  quantity  is  usually  about  normal,  ranging  from  30  to  50  c.c. 
and  the  ratio  of  the  liquid  layer  to  the  layer  of  sediment  is  unchanged 
from  that  of  the  healthy  test  breakfast. 

In  rarer  cases  the  total  quantity  is  excessive,  often  from  200  to  250 
c.c,  and  is  composed  largely  of  fluid,  the  depth  of  the  supernatant  fluid 
being  three  to  five  times  the  depth  of  the  sediment.  This  form  of  test 
breakfast  is  described  under  alimentary  hypersecretion,  page  530. 
It  would  seem  plausible  to  assume  that  this  excessive  outpouring  of 
fluid  containing  no  hydrochloric  acid  was  due  to  an  oversecretion  or 
rather  to  an  excessive  transudation  of  the  osmotic  thinning  fluid 
described  by  Strauss. 

These  three  forms  of  achylia  occur  with  the  same  symptoms  and 
under  the  same  conditions,  and  the  writer  does  not  know  how  to  divide 
them  according  to  any  scientific  classification.  One  form  does  not. 
however,  merge  into  another,  dry  achylia  remains  so  throughout,  wet 
achylia  remains  wet  achylia,  the  granular  form  does  not  change  its 
appearance  so  as  to  resemble  either  of  the  other  forms. 


506  ACHY  LI  A 

A  faint  biuret  test  is  nearly  always  present.  Starch  reactions  are 
usually  carried  to  the  maltose  stage.  Erythrodextrin  reactions  are 
exceedingly  weak  or  absent. 

Pepsin  activity  is  usually  reduced,  although  it  may  be  that  zymogens 
are  present  in  full  activity. 

It  has  been  attempted  by  estimation  of  the  strength  of  zymogen  in 
various  dilutions  to  form  some  idea  of  the  extent  to  which  the  glandular 
structures  have  been  affected.  The  method  of  testing  zymogen  activity 
and  the  conclusions  which  are  warranted  by  such  tests  are  given  on 
page  58. 

While  in  a  general  way  these  conclusions  may  serve  as  a  guide  in 
our  prognosis,  they  are  not  always  to  be  relied  upon,  and  we  are  not 
warranted  in  expressing  ourselves  too  definitely  as  to  the  gravity  of 
the  case  by  this  test  alone. 

Treatment. — The  chief  indication  for  treatment  is  to  select  a  diet 
which  does  not  call  too  loudly  for  gastric  digestion,  but  which  can 
undergo,  by  the  salivary,  pancreatic,  and  intestinal  secretions  the 
changes  requisite  for  its  proper  absorption.  For  this  purpose  the 
carbohydrates  may  be  given  freely,  fats  should  be  slightly  reduced, 
])roteids  given  but  sparingly. 

Dietetic  Treatment. — ]\Iuch  depends  on  the  selection  of  a  proper 
diet  upon  the  severity  of  the  symptoms  presented.  To  insist  too 
strenuously  upon  a  diet  composed  chiefly  of  invalid  foods,  or  of  pre- 
digested  nourishment,  while  perfectly  suitable  for  one  with  whom  con- 
stant and  exhausting  diarrhea,  would  be  extremely  injudicious  and 
unnecessary  for  another  who  is  free  from  all  discomfort  and  in  whom 
achylia  has  been  found  as  the  result  of  a  routine  examination  of  gastric 
contents.  Good  common-sense  must  be  used  in  the  selection  of  a  diet 
that  the  patient  can  continue  for  a  long  period  of  time  without  aversion, 
and  which  is  adequate  to  preserve  a  good  nutrition  and  a  normal  weight. 
It  will  be  found  convenient  to  consider  the  diet:  (1)  in  those  who  have 
no  gastric  or  intestinal  symptoms  and  (2)  in  those  with  diarrhea. 

1.  In  th(>  ordinary  case  of  achylia  without  diarrhea,  it  is  usually 
sufficient  to  eliminate  all  red  meats,  allowing  fish,  chicken,  and  fowl 
(except  goose  and  domestic  duck).  Lamb  and  tender  mutton  may 
occasionally  be  taken,  although  it  must  be  insisted  that  they  be 
thoroughly  cooked  so  that  the  connective-tissue  framework  of  the 
meat  is  soft  and  the  more  easily  digested  by  the  intestinal  secretions. 
Eggs  may  be  given  to  bring  the  total  ])roteid  value  uj)  to  the  requisite. 

Thorough  mastication  is  essential  both  to  macerate  the  food  and 
bring  in  into  close  contact  with  the  salivary  ferment,  and  to  prevent 
the  introduction  of  large  masses  of  food  into  the  stomach  and  thence 
>uichaiiii;c(l  into  the  bowel.     Defective  teeth  should  receive  immediate 


TREATMENT  OF  ACUVL/A  oO/ 

attention.  Food  should  he  finely  eut,  or  even  minced.  A'cj^etahles 
should  by  i)reference  he  mashed  l)y  a  fork,  or  put  thnuigh  a  puree  sieve 
— they  should  ne\'er  he  swallowed  in  large  i)ieces.  Beef  broths,  con- 
somme, and  peptone  solutions  may  be  given  for  their  stimulating  effect 
upon  the  gastric  glands. 

It  is  not  advisable  to  recommend  highly  seasoned  or  overspiced  food, 
or  alcoholic  "appetizers"  for  this  purpose,  as  by  so  doing  we  may 
increase  gastric  inflammation,  of  which  achylia  is  the  evidence.  Haw 
fruit  is  generally  inadvisable  owing  to  the  excessive  amount  of  cellulose. 
Cooked  fruit  may  be  taken  freely  except  when  there  is  a  tendency 
toward  morning  diarrhea. 

The  diet  must  be  varied  so  that  the  patient  escapes  the  deadly 
monotony  of  eating  the  same  food  day  after  day,  and  on  the  other  hand 
should  be  reasonably  within  his  means.  Laboring  men  cannot  afford 
chickens  and  fresh  fish.  For  them  thoroughly  cooked  stews  may  be 
allowed.    A  sample  diet  is  as  follows: 

Breakfast: 

Cup  of  coffee,  or  cocoa.  Math  cream  or  sugar.  Cereal,  with  cream 
and  sugar,  or  saccharin.  Two  soft-boiled  or  poached  eggs.  Rolls, 
toast,  pulled  bread,  or  zwiebach.  Moderate  amount  of  butter,  prefer- 
ably unsalted.  Strained  pure  honey,  such  as  Sheffield  Farms.  Orange 
marmalade  or  any  Dundee  jam.    Xo  hot  bread.    Xo  fruit. 

10  to  11  A.M. 

Choice  of:  Glass  of  top  milk  or  cream,  or  milk  and  cream,  with 
crackers.  Cup  custard.  Malted  milk.  Junket.  Buttermilk  or  lactone 
milk.     Russell's  emulsion.     Egg  shake. 

Luncheon: 

None:  Liquids  restricted  to  less  than  one  glass.  X'^o  steak,  roast  beef, 
sweetbreads,  kidneys,  pork.  X'o  salt  fish  or  shell-fish.  Xo  radishes, 
raw  celery.    No  anchovy.    Xo  oranges,  grape  fruit,  or  raw  apples. 

billowed:  Soup,  fresh  fish,  chicken,  turkey,  fowl  of  all  kinds,  save 
domestic  duck  and  goose;  lamb,  mutton,  lean  broiled  or  boiled  ham 
(occasionally).  Simply  prepared  ragout.  Oysters  in  any  form.  Olives 
and  caviar  allowed. 

Freely:  Potatoes  in  any  form,  except  fried;  boiled  potatoes  only 
occasionally,  and  then  well  masticated.  Carrots  and  turnips,  etc., 
if  passed  through  a  puree  sieve.  Tender-boiled  onions,  tender  beets, 
oyster  plant,  peas,  beans,  spinach,  rice,  macaroni,  spaghetti,  samp,  etc. 

Occasional:  Cauliflower,  stewed  celery,  Brussels  sprouts,  asparagus 
tips.     Bread  if  not  too  fresh.     Salad  with  French  dressing.     Cheese. 

Desserts:  Rice  pudding,  farina,  corn-starch,  blanc-mange,  prune 
souffle,  ice-cream,  but  no  fruit  ices,  stewed  figs,  or  prunes;  baked  apple 
with  cream,  etc. 


508  ACHY  LI  A 

4  to  5  P.M. 

Same  variety  as  11  a.m.,  with  the  additional  choice  of  cocoa  or  choco- 
late, with  cream  or  sugar,  or  a  farinaceous  dessert,  as  on  luncheon  list. 

Dinner: 

Same  variety  as  lunch. 

10  P.M. 

Same  variety  as  11  a.m. 

While  liquids  are  restricted  at  meals,  water  may  he  taken  freely 
between  meals. 

2.  When  diarrhea  occurs,  showing  imperfect  digestion,  the  diet 
must  be  more  strict.  The  writer's  second  and  third  week  ulcer  diet 
should  be  advised  as  long  as  diarrhea  persists.  If  despite  this  stricter 
diet  the  diarrhea  should  continue,  the  patient  should  be  confined  to 
bed,  hot  applications  constantly  applied  to  the  whole  abdomen  in  the 
manner  described  in  ulcer,  and  the  diet  continued.  The  patient  should 
be  kept  in  bed  until  he  can  take  the  more  general  diet  given  above 
without  return  of  the  diarrhea. 

Medicinal  Treatment. — The  majority  of  patients  require  no  medication 
provided  that  the  diet  is  correct.  Other  patients  are  benefited  by 
hydrochloric  acid  given  in  some  form  or  another.  The  dilute  acid  may 
be  given  in  TTixv  to  xx  doses  well  diluted  during  or  after  meals,  either 
plain,  or  with  some  one  of  the  aromatic  elixirs,  such  as  the  elixir  of  cali- 
saya.  The  tincture  of  nux  ^'()mica  or  of  physostigma  should  be  added 
if  atony  coexist.  It  is  doubtful  if  the  acid  is  of  any  direct  help  to  gastric 
digestion,  as  the  quantity  that  can  be  given  is  so  small,  but  empirically 
good  results  follow  its  use,  perhaps  as  an  excitor  of  the  formation  of 
secretin.  There  seems  to  be  no  more  benefit  derived  from  taking  the 
acid  between  meals  than  at  the  table,  and  it  is  far  less  convenient. 

Oxyntin,  an  acid  albumin  manufactured  by  Fairchild  Bros.  &  Foster, 
is  convenient  and  efficient.  A  teaspoonful  of  the  ])owder  may  be  taken 
either  in  wafer  paper  or  placed  in  sandwich  form  between  small  slices 
of  bread  and  butter  and  taken  at  the  meals.  Two  grains  of  oxyntin 
are  equivalent  in  therapeutic  value  to  one  minim  of  the  dilute  hydro- 
chloric acid  of  the  Pharmacopoeia. 

(lasterin  and  hepatin  consist  of  the  gastric  juice  of  dogs  o})tained 
through  artificial  gastric  fistulas.  These  ])reparations  are  exceedingly 
active  as  digestants,  but  they  are  expensive,  ha\e  to  be  freshly  obtained, 
and  kejjt  in  a  cool  place,  and  it  is  a  question  whetlier  they  are  enough 
better  than  the  officinal  acid  to  be  worth  the  trouble. 

Acidol  tablets  occur  in  two  strengths.  The  stronger  tablet  represents 
in  strength  eight  minims  of  the  dilute  acid,  the  weaker  tablet  but  two 
minims.  These  tablets  are  to  be  dissolved  in  water  and  taken  at  meals. 
They  are  of  special  service  in  the  dysj^epsia  of  aged  subjects. 


TREATMENT  OF  ACHY  LI  A  509 

Pepsin  is  now  hut  rarely  jjiven.  The  majority  of  the  j)reparati()ns  in 
the  market  are  inert. 

Pancreatin  anci  panereon  may  he  jj^iven  to  aid  intestinal  digestion. 
They  should  be  combined  with  alkalies  and  given  at  least  two  hours 
after  meals. 

Carotid  and  papoid  tablets  are  much  in  vogue,  although  the  writer 
has  not  been  impressed  by  their  value. 

Secretin  on  the  other  hand  seems  to  be  of  very  great  service  as  a 
stimulant  to  pancreatic  activity.  The  tablets  made  by  Fairchild  Bros. 
&  Foster  should  be  given  two  hours  after  meals,  either  alone  or  com- 
bined in  a  capsule  with  a  tablet  of  acidol.  The  addition  of  eserine 
gr.  ViT  is  of  service.  There  is  no  doubt  that  given  in  this  way  secretion 
is  a  valuable  addition  to  our  list  of  remedies. 

For  the  diarrhea,  astringents  should  not  be  used — rest  in  bed,  ex- 
ternal moist  heat,  and  diet  usualh^  bring  speedy  relief.  Tricalcic  ortho- 
phosphate  in  dram  doses  may  be  given  between  meals  three  times  a 
day,  or  gr.  xv  of  calcium  lactate  at  like  intervals.  These  calcium 
preparations  can  be  recommended  by  the  writer  in  achylia  diarrheas 
whether  the  patient  is  sent  to  bed  or  is  allowed  to  be  up  and  around. 

Diarrhea  is  so  frequently  aggravated  by  an  increase  in  intestinal 
peristalsis  that  small  doses  of  strontium  bromide  are  to  be  recommended 
as  a  routine  procedure  in  nearly  every  case. 

Castor  oil  (TTL  x)  and  salol  (gr.  x)  in  capsule  are  often  of  value  in 
diminishing  abdominal  discomfort  and  unrest.  Xeroform  in  gr.  x  doses 
three  times  a  day  may  be  also  recommended. 

Mineral  ivaters  are  of  service  only  w^hen  the  achylia  results  from 
gastric  catarrh  or  is  accompanied  by  gall-bladder  disease. 

In  the  former  case  hot  Kissingen  (Rakoczy)  before  meals  may  be 
given.  It  seems  to  be  of  no  service  in  dry  achylias  nor  in  the  cases  in 
which  the  zymogens  are  greatly  reduced  in  activity. 

In  the  gall-bladder  cases,  Carlsbad  may  be  recommended,  although 
theoretically  contra-indicated  in  conditions  of  anacidity.  It  is  to  be 
used  sparingly,  however,  so  that  its  effect  on  the  bowels  is  reduced  to  a 
minimum,  one  unformed  movement  daily  being  the  limit. 

]\Iedicinal  waters  are  contra-indicated  in  all  cases  complicated  by 
atony  or  other  motor  error,  and  in  cases  with  diarrhea. 

Lavage  is  indicated  only  in  those  cases  in  which  the  washing  of  the 
stomach  in  the  fasting  state  brings  in  the  wash-water  large  quantities 
of  mucus.  The  secretion  of  mucus  in  the  fasting  state  is  rather  uncom- 
mon in  achylia,  and  therefore,  the  number  of  patients  in  whom  lavage 
is  indicated  is  exceedingly  small.  There  is  no  benefit  to  be  derived 
from  lavage  in  the  cases  whose  gastric  contents  and  test  breakfasts 
show  mucus,  but  in  whom  mucus  is  not  present  in  the  fasting  stomach. 


THAPTER   XIX 

HYPERSECRtniON   (GASTROSrCX;ORRHEA  OR 
"REICHMANN'S  DISEASE") 

The  disorder  which  we  call  hypersecretion  is  distinguished  from 
other  disturbances  of  the  stomach  by  the  fact  that  gastric  juice  is 
poured  out  in  far  greater  quantity  than  is  required  for  the  purposes 
of  digestion.  The  oversecretion  may  occur  both  in  the  digesting  and 
in  the  fasting  state,  so  that  not  only  is  there  an  increased  amount  of 
gastric  juice  secreted  with  the  test  breakfast,  but  demonstrable  quan- 
tities of  the  same  acid  fluid  are  to  be  found  in  the  fasting  stomach.  To 
this  form  the  term  "continuous  hypersecretion"  is  applied.  In  other 
cases  an  excessive  quantity  of  gastric  juice  is  secreted  only  when  food 
is  present  in  the  stomach,  and  ceases  when  the  stomach  empties  itself. 
This  is  spoken  of  as  "  alimentary"  or  "  digestive"  hypersecretion.  These 
two  forms  will  be  separately  described. 

Continuous  hypersecretion  generally  occurs  as  a  chronic  process 
either  running  a  more  or  less  uniform  course,  or  in  some  instances 
interrupted  by  exacerbations  often  so  sudden  and  severe  that  they 
seem  to  indicate  an  acute  manifestation  of  disease.  In  other  cases 
the  disorder  may  unexpectedly  appear  without  the  least  indication 
that  there  has  previously  existed  any  evidence  of  the  chronic  form  of 
the  derangement.  Acute  and  chronic  forms  are  therefore  to  be 
recognized. 

ACUTE    HYPERSECRETION 

Acute  h\})ersecretion  may  appear  as  a  new  and  acute  disorder, 
although  in  the  majority  of  cases  it  will  be  found  to  represent  an  acute 
exacerbation  of  the  chronic  form  which  may  or  may  not  have  been 
previously  recognized. 

Etiology. — Formerly  little  was  known  about  the  cause  for  the  com- 
l>laiiit.  It  was  supposed  to  be  commonest  among  young  excitable 
individuals,  especially  those  who  are  the  victims  of  a  neurotic  inheri- 
tance. Attacks  were  ascribed  to  overexcitement  and  cerebral  fatigue. 
It  was  said  to  occur  frequently  in  learned  men  who  gave  way  to  attacks 
of  anger  or   overindulgence   in   alcohol.      In   other    instances   dietetic 


ACUTE  HYPERSECRETION  511 

errors  haAe  l)een  responsible.  These  theories  are  now  generally  aban- 
doned.  Acute  periodic  hypersecretion  as  a  pure  neurosis  does  not  occur. 

Certain  attacks  of  gastric  crisis  in  locomotor  ataxia  are  supposed 
to  be  due  to  acute  hypersecretion,  and  there  are  instances  in  which  there 
seems  to  be  an  intimate  connection  between  the  two  conditions,  but 
there  is  little  if  any  proof  that  a  direct  excitation  of  secretory  nerve 
stimulus  is  the  real  reason  for  the  excessive  and  continuous  hyper- 
secretion. It  is  more  probable  that  a  spasmodic  condition  of  the  pyloric 
sphincter  is  induced  by  the  spinal  disease  which  manifests  itself  in  over- 
secretion. 

^Modern  clinical  observation  illuminated  by  the  light  of  surgical 
explorations  and  operations  lead  us  to  the  belief  that  acute  hypersecre- 
tion occurs  only  from  sudden  narrowing  of  the  pyloric  canal  either 
from  organic  causes,  such  as  juxtapyloric  ulcer  or  from  a  muscular 
spasm  of  the  pyloric  sphincter.  In  the  majority  of  cases  a  combination 
of  organic  stenosis  and  spasm  are  to  be  held  responsible  for  the  event. 
A  pylorus  that  has  been  partially  narrowed  by  the  tumefaction  of  an 
acute  ulcer  or  by  the  cicatrization  of  one  that  is  more  chronic  may 
suddenly  close  down  by  an  extension  or  recrudescence  of  the  ulcerative 
process  by  tumefaction  or  spasm  and  give  rise  to  acute  hypersecretion. 
After  the  spasm  has  relaxed  or  the  tumefaction  subsided  the  acute 
symptoms  abate,  but  it  is  rare  indeed  that  there  are  not  then  found 
evidences  of  a  milder  but  more  chronic  form  of  the  malady,  so  that 
it  would  appear  that  the  acute  hypersecretion  was  but  an  acute 
exacerbation  of  a  chronic  disorder. 

Symptoms. — As  acute  hypersecretion  is  regularly  due  to  sudden 
pyloric  narrowing,  either  organic,  spasmodic,  or  to  a  combination  of 
these  two  conditions,  a  previous  history  indicative  of  some  morbid 
process  involving  directly  or  indirectly  the  patency  of  the  pyloric 
orifice  may  generally  be  elicited.  In  the  vast  majority  of  instances  the 
history  of  a  preexisting  gastric  or  duodenal  ulcer  can  be  obtained; 
more  rarely  may  there  have  been  symptoms  of  a  pyloric  neoplasm. 
In  reflex  pylorospasm  from  gall-bladder  or  appendicular  disease  a  pre- 
vious history  indicative  of  either  of  these  disorders  may  be  difficult 
to  obtain  with  any  clean-cut  definition,  and  even  may  be  entirely 
impossible  to  elicit  in  any  form  whatever. 

In  other  cases  no  symptoms  of  any  preexisting  disorder  may  have 
been  observed,  but  the  phenomena  of  hypersecretion  appear  from  a 
clear  sky,  or  after  a  trifling  indigestion  attributed  by  the  patient  to 
some  d  etetic  error. 

The  first  symptoms  are  those  of  discomfort  or  distress.  There  are 
uneasy  feelings  in  the  epigastrium  which  the  patient  is  often  unable 
to  describe  with  any  accuracy.    There  may  be  a  sense  of  fulness  and 


512 


//  YPERSECRETION 


distention,  as  if  the  })atient  has  overeaten,  or  a  feehng  of  weakness  and 
soreness  in  the  back,  so  that  the  patient  will  attempt  to  straighten  the 

})ack  hoping  to  reheve  the  distress.    In 
Fig-  108  ^}ie  majority  of  cases  pain  is  the  chief 

complaint,  is  of  a  burning  or  boring 
character,  and  is  quite  severe  and 
harassing.  These  painful  or  disagree- 
able sensations  are  regularly  continu- 
ous, slightly  relieved  for  the  time  by 
the  taking  of  food  or  alkalies,  but  soon 
returning  as  severely  as  ever.  If  soda 
be  taken  in  large  enough  doses  the 
relief  may  be  quite  marked  for  the 
time,  although  gaseous  distention  of 
the  stomach  by  the  liberated  (^02 
often  increases  the  general  discomfort 
and  fulness.  Complete  relief  is  afforded 
only  by  the  emptying  of  the  stomach 
either  by  emesis  or  by  the  tube,  but  the 
period  of  comfort  is  but  temporary  as 
the  symptoms  return  when  the  stomach 
becomes  again  filled  with  the  acid  fluid. 
Character  of  Vomitus. — The  character 
of  the  vomitus  is  pathognomonic  of  the 
condition. 

1.  The  vomitus  consists  almost  en- 
tirely of  fluid  giving  reactions  for  free 
hydrochloric    acid.     The   color   may   be   yellowish   or   greenish   from 
admixture  of  bile  that  may  l)e  regurgitated  even  though  the  pylorus 


Vomited  fluid  of  acute  hypersecretion  in 
.1  case  of  acute  gastric  ulcer.  The  vomit- 
ing of  this  quantitj'  occurred  thirty-five 
hours  after  total  abstinence  from  food  and 
drink.     Measurement  in  centimeter.s. 


Fio.   109 


^VOMITING  

CUP  OF  TEA    0    1   ACID  FLUID    nq  DINNER 


Line  of  pain  in  acute  hypersecretion  from  a  patient  with    acute   duodenal  ulcer  showing 
inOuencc  of  food,  alkalies,  and  vomiting,  on  the  pain. 


be  narrowed,  or  l)r()wnisli  from  altered  blood.  I^'ood  remains  may  be 
present  if  food  has  recently  been  ingested,  but  usually  the  bulk  of  the 
vomitus  is  of  Huid  alone. 


ACUTE  HYPERSECRETION  513 

2.  The  vomited  liquid  is  in  greater  quantity  than  can  be  accounted 
for  by  fluids  recently  taken,  and  is  usually  quite  excessive,  one  or  more 
pints  being  ejected  "by  gushes."  Very  characteristic  is  this  excessive 
fluid  vomiting  when  the  patient  has  been  deprived  for  some  time  of 
all  nourishment;  the  patient  "wonders  where  all  the  fluid  comes  from." 
E^'en  though  the  patient  may  have  been  fasting  for  twenty-four  or 
more  hours,  two  or  three  basinsful  may  be  collected  during  the  night. 
Actual  nausea  is  rare,  the  vomiting  being  usually  preceded  by  a  short 
period  of  fulness  and  uneasiness  followed  by  effortless  vomiting  of  the 
acid  liquid.  During  the  attack  the  patient  shows  rapid  exhaustion 
and  loss  of  weight.  The  pulse  becomes  small  and  thready,  the  body 
temperature  depressed.  Thirst  is  bitterly  complained  of,  but  every 
attempt  to  assuage  it  is  followed  by  gastric  unrest  and  a  repetition  of 
the  vomiting. 

Other  Symptoms. — In  some  instances  severe  headache  with  photo- 
phobia, suffusion  of  the  conjunctiva,  and  even  temporary  diplopia 
may  be  observed,  closely  resembling  migraine.  Transient  delirium  has 
been  known  to  occur.  The  cephalalgia  seems  to  depend  upon  the 
presence  of  the  acid  fluid  within  the  stomach,  for  it  promptly  ceases 
whenever  the  stomach  is  emptied  by  lavage  or  emesis.  To  acute 
hypersecretion  accompanied  by  migraine,  Rossbach  gave  the  name  of 
"gastroxynsis."  Whether  the  migraine  causes  the  hypersecretion,  or 
whether  hypersecretion  occurs  first  and  is  then  followed  by  a  systemic 
headache,  cannot  be  dogmatically  decided.  The  writer  believes  that  in 
the  vast  majority  of  cases  the  migraine  is  merely  symptomatic  of  the 
secretory  disorder.  In  his  experience  typical  periodical  migraine  with 
a  resulting  hypersecretion  has  not  been  observed.  A  purely  neurotic 
form  of  acute  periodical  hypersecretion  may  be  disregarded. 

The  bowels  are  regularly  constipated.  The  urine  is  diminished  in 
quantity  and  shows  the  characteristics  of  concentration.  The  chlorides 
are  reduced,  urea  is  diminished.  The  urine  may  present  a  peculiar  glis- 
tening appearance  due  to  the  presence  of  numberless  uric  acid  crystals, 
which  according  to  Fenwick  precede  the  attack  and  indicate  the  prox- 
imity'of  the  crisis.  Positive  reactions  for  acetone  and  diacetic  acid 
may  frequently  be  obtained.  During  the  attack  the  upper  abdominal 
wall  may  be  retracted — the  epigastrium  is  usually  diffusely  tender. 
Gastric  stiffening  is  rarely  observed,  indications  of  an  increased  peris- 
talsis are  seldom  present.  Splashing  sound  may  be  audible  by  gentle 
tapotement  unless  the  abdominal  wall  be  thick  or  rigid,  and  are  quite 
suggestive  of  the  derangement  if  they  are  heard  when  the  stomach 
should  be  empty. 

The  attack  often  subsides  abruptly.  Occasionally  the  crisis  is  marked 
by  gurgling  noises  in  the  stomach  and  by  a  feeling  that  an  internal 
33 


514  HYPERSECRETION 

spasm  has  suddenly  relaxed.  As  soon  as  the  paroxysm  is  over  the  patient 
is  able  to  take  nourishment,  and  within  a  few  hours  may  declare  that 
he  feels  as  well  as  ever,  although  examination  may  show  a  considerable 
amount  of  acid  fluid  still  remaining  in  the  stomach,  indicating  that  a 
mild  form  of  hj^persecretion  still  exists  without,  however,  giving  rise 
to  noticeable  symptoms. 

Duration  and  Course. — The  duration  of  the  attack  varies  from  a 
few  hours  to  several  days  in  the  ordinary  cases;  the  subsidence  may  be 
complete  or  the  condition  may  gradually  merge  into  that  of  the  chronic 
form.  During  the  course  of  chronic  ulcer  with  chronic  hypersecretion, 
acute  exacerbations  may  occur  of  great  severity  and  may  last  without 
remission  until  the  patient  is  relieved  by  operation  or  dies  exhausted. 

The  varieties  in  the  course  of  acute  hypersecretion  are  fully  described 
under  the  heading  of  ulcer. 

Diagnosis. — No  difficulty  whatever  should  arise  when  a  patient 
begins  to  vomit  large  quantities  of  acid  fluid  and  continues  to  do  so 
after  the  stomach  has  once  been  emptied.  To  call  such  cases  acute 
indigestion  or  acute  gastritis  implies  culpable  ignorance  or  neglect. 
Difficulty  may  be  experienced,  however,  in  recognizing  this  ailment 
before  the  event  of  vomiting.  It  is  always  suggestive  when  a  patient, 
especially  if  there  be  an  ulcer  history,  complains  of  a  constant  epigastric 
distress  relieved  slightly  and  temporarily,  if  at  all,  by  eating  or  by 
alkalies  in  average  doses.  The  passage  of  a  stomach-tube  will  at  once 
reveal  the  cause  for  the  suffering. 

Acute  hypersecretion  is,  however,  merely  a  symptom-complex  of 
pyloric  obstruction  in  one  form  or  another,  and  the  diagnosis  is 
incomplete  unless  we  are  able  to  discover  the  underlying  cause  for  the 
sudden  loss  of  patency.  The  previous  history  should  be  most  carefully 
taken,  especially  in  reference  to  possible  ulcer  or  cancer,  and  to  attacks 
of  gall-bladder  or  appendicular  disease.  The  absence  of  any  data 
indicating  the  previous  existence  of  any  of  these  disorders  does  not 
necessarily  exclude  them  as  possibilities.  In  children  reflex  pyloro- 
spasm  from  inflamed  and  adherent  prepuce  may  occasion  recurring 
outbreaks  of  excessive  gastric  secretion. 

In  every  case  the  gastric  crisis  of  tabes  must  be  considered  as  a 
possibility,  unless  it  can  be  excluded  by  the  absence  of  characteristic 
symptoms  and  physical  signs,  remembering,  however,  that  attacks  of 
gastric  crisis  may  occur  during  the  preataxic  stage  of  the  spinal  disease. 
In  gastric  crisis  the  vomited  matters  are  not  always  hyperacid,  they 
may  be  subacid  or  even  alkaline,  and  the  emesis  is  not  followed  by 
the  same  tranquillity  that  occurs  with  acute  hypersecretion. 

It  is  of  importance  to  discriminate,  if  possible,  between  pyloric 
spasm  and  organic  stenosis.    The  two  conditions  are  often  combined 


ACUTE  HYPERSECRETION  515 

so  that  separation  of  the  pyloric  narrowing  into  two  component  parts 
is  naturally  difficult.  The  more  sudden  the  attack  and  the  shorter  its 
duration  the  greater  the  probability  of  spasm.  Hypersecretion  from 
reflex  pylorospasm  due  to  appendix  or  gall-bladder  disease  is  rarely 
severe  and  seldom  continues  longer  than  twelve  to  twenty-four  hours. 
Attacks  which  last  more  than  two  days  are  almost  certainly  due  to 
organic  stenosis  with  or  without  a  concomitant  spasm.  In  attacks 
lasting  four  or  five  days  an  organic  cause  may  be  considered  certain, 
and  the  spasm  element  practically  negligible.  The  degree  of  per- 
manent constriction  of  the  pylorus  can  best  be  determined  by  a 
series  of  gastric  analyses  made  after  the  acute  manifestations  of  the 
malady  have  subsided. 

Illustrative  Cases.  —  Acute  Hyyersecretion  Attacks  Due  to  Chronic 
Ulcer. — Mrs.  H.,  aged  thirty-five  years,  was  well  until  one  year  ago, 
when  she  began  to  suffer  from  attacks  of  gnawing  pain  in  the  stomach 
relieved  only  slightly  by  eating  or  taking  soda,  but  completely  relieved 
for  the  time  being  by  vomiting.  During  such  an  attack  she  would 
vomit  whether  she  ate  or  not,  the  vomited  matters  consisting  of  acid 
water  which  would  come  up  "by  great  gulps."  These  attacks  would 
continue  twenty-four  to  forty-eight  hours  and  then  suddenly  subside, 
leaving  her  quite  well  in  the  intervals,  until  two  months  ago,  when  she 
began  to  complain  of  more  constant  distress  and  heart-burn  appearing 
about  two  hours  after  meals  totally  relieved  by  eating.  Six  weeks 
ago  she  began  one  of  her  periodical  acute  attacks  in  which  she  vomited 
acid  water  for  fourteen  days,  although  she  took  very  little  food.  Five 
days  ago  another  attack  began  and  since  then  she  has  vomited  from 
2  to  4  pints  daily  of  acid  fluid  (total  acidity  104,  free  hydrochloric  acid 
86),  although  the  total  amount  of  liquid  she  has  been  able  to  take  has 
not  exceeded  10  ounces  a  day. 

Operation  shows  chronic  ulcer  of  the  lesser  curvature  encroaching 
upon  the  pyloric  canal. 

Acute  Hypersecretion  ivith  Cancer. — J.  S.  M.,  aged  forty-seven  years, 
was  a  healthy  man  until  six  weeks  ago,  when  he  began  to  complain  of 
burning  distress  in  the  stomach  unrelieved  by  eating  or  alkalies,  and 
from  time  to  time  vomiting  large  quantities  of  a  dark  brown  acid  fluid. 
The  day  before  admission  he  awoke  with  distress  in  the  stomach,  and 
before  breakfast  there  were  withdrawn  by  the  tube  3  pints  of  acid  fluid, 
total  acidity  98,  free  hydrochloric  acid  (34.  Nothing  was  given  by  mouth 
until  the  following  morning  at  S  o'clock,  when  he  vomited  2  quarts  of 
acid  brown  fluid  and  one  and  a  half  hours  later  an  equal  quantity  of  the 
same  fluid  was  removed  by  the  tube,  making  4  quarts  in  all  that  were 
withdrawn  from  his  fasting  stomach.  Total  acidity  106,  free  hydrochloric 
acid  80.  He  was  operated  on  the  following  morning  and  a  carcinoma 
of  the  pylorus  with  infiltration  of  the  gastrocolic  omentum  was  found. 


516  HYPERSECRETION 

Acute  Hypersecretion  with  Chronic  Appendicitis. — S.  J.,  aged  forty- 
five  years,  for  a  number  of  years  has  complained  of  acidity  and  heart- 
burn, appearing  usually  but  not  invariably  at  a  definite  time  after  eating, 
but  always  relieved  by  soda.  During  the  past  two  years  he  has  had 
attacks  of  a  burning  distress  which  would  appear  during  the  forenoon 
and  increase  during  the  day,  not  relieved  by  eating  and  but  slightly 
by  soda.  The  distress  would  prevent  his  sleeping  until  about  one  or 
two  o'clock  in  the  morning.  He  would  then  vomit  his  dinner,  together 
with  copious  quantities  of  very  acid  fluid  and  then  be  comfortable, 
sleep  well  the  remainder  of  the  night  and  awake  as  usual  in  the  morning. 
Operation  showed  a  chronic  obliterated  appendix  which  was  removed. 
No  ulcer  could  be  demonstrated,  gall-bladder  normal.  Since  his  opera- 
tion he  has  not  been  troubled  by  any  of  his  former  complaints. 

Acute  Hypersecretion  Due  to  Adherent  Prepuce. — C.  P.,  aged  twelve 
years,  had  never  had  any  trouble  with  his  stomach  until  the  past  few 
years,  during  which  time  he  has  had  a  number  of  attacks  of  persistent 
vomiting  of  acid  fluid,  lasting  twenty-four  to  thirty-six  hours.  The 
termination  of  each  attack  was  abrupt,  and  in  the  interval  he  was  free 
from  all  the  symptoms.  His  attacks  ceased  altogether  after  operation 
for  elongated  and  adherent  prepuce. 

Prognosis. — The  prognosis  depends  largely  upon  the  cause.  The 
longer  the  attack  and  the  more  copious  the  hypersecretion,  the  greater 
is  the  liability  of  there  being  an  organic  cause  which  requires  surgical 
consideration,  and  the  less  the  likelihood  of  a  simple  spasm.  The 
danger  of  hemorrhage  either  from  exacerbation  of  a  preexisting  ulcer 
or  from  hemorrhagic  erosions  that  result  from  prolonged  and  violent 
pyloric  spasm  must  alw^ays  be  considered.  In  severe  and  prolonged 
attacks  tetany  may  occur. 

Treatment. — The  first  indication  for  treatment  is  to  relieve  pyloric 
spasm,  hoping  to  cut  short  the  attack  and  to  minimize  the  tendency 
toward  erosions  and  hemorrhages.  All  food  and  drink  should  be  abso- 
lutely interdicted  and  the  stomach  should  be  emptied  either  by  emesis 
or  preferably  through  the  tube.  Alkalies  should  be  given  in  sufficient 
doses  to  neutralize  the  acid  fluid  that  may  be  in  the  stomach.  P^^xternal 
heat  is  not  onl}^  of  service  in  reducing  the  spasm  but  also  in  alleviating 
the  distress.  Atropine  is  a  useful  drug  pushed  to  mild  physiological 
limits,  but  it  increases  the  thirst  that  is  in  itself  intolerable.  Mor- 
phine should  not  be  used  unless  the  pain  be  so  great  and  unrelieved  by 
other  forms  of  medication  that  something  has  to  be  done  to  alleviate 
the  distress. 

In  every  case  there  arises  the  question  of  operation.  If  acute  ulcer 
be  the  probable  cause  it  is  better  not  to  operate,  as  in  all  probability 
the  attack  will  subside  and  the  ulcer  will  heal  under  medical  treatment 


CHRONIC  HYPERSECRETION  517 

alone.  In  chronic  ulcer  the  disease  is  one  which  requires  the  soundest 
judgment.  If  we  knew  that  the  attack  would  be  of  short  duration  our 
advice  would  naturally  be  to  wait  until  the  acute  symptoms  had 
subsided.  The  danger  Hes  in  waiting  too  long  so  that  the  operation  is 
performed  upon  a  patient  exhausted  by  repeated  vomiting,  whose 
tissues  are  desiccated  by  the  rapid  withdrawal  of  w^ater  from  the  system. 
Experience  shows  that  these  patients  are  not  good  subjects  for  opera- 
tion. It  may  be  said,  as  a  general  rule,  that  if  the  attack  continues 
after  fort^^-eight  hours,  in  spite  of  medical  treatment,  immediate 
operation  must  be  considered.  It  is  important,  however,  to  introduce 
fluids  into  the  system  before  the  operation,  either  by  enemas  or  the 
Murphy  drip,  or  if  the  case  be  urgent,  by  hypodermoclysis. 

The  above  rules  for  treatment  apply  also  to  the  cases  that  are  due 
to  cancer  of  the  pylorus.  In  hypersecretion  accompan^'ing  gall-bladder 
or  appendicular  disease  the  question  of  immediate  operation  seldom 
if  ever  is  forced  upon  us,  as  the  attack  is  regularly  short.  After  the 
attack  is  over  there  may  arise  the  question  of  operating  for  the  relief 
of  the  primary  disease.  Each  case  must  then  be  decided  upon  its  own 
merits. 

CHRONIC   HYPERSECRETION 

Chronic  hypersecretion  is  characterized  by  the  constant  presence  of 
gastric  juice  in  the  fasting  stomach.  Before  this  diagnostic  rule  can  be 
applied  it  must  be  assumed  that  the  normal  fasting  stomach  is  empty, 
or  practically  so,  and  this  fact  is  universally  acceded.  Small  quantities 
of  fluid  giving  acid  reactions  may  occur  in  the  normal  stomach  but 
not  usually  exceeding  10  c.c.  in  amount.  Larger  quantities,  from  20 
to  30  c.c,  may  occasionally  be  found  in  otherwise  healthy  stomachs 
as  a  temporary  occurrence,  but  such  a  hypersecretion  cannot  usually 
be  demonstrated  on  subsequent  examinations.  The  idea  has  been 
absolutely  abandoned  that  overstimulation  of  the  gastric  glands  may 
result  from  the  mechanical  irritation  of  a  stomach-tube. 

The  fluid  must  be  pretty  constantly  found  in  the  fasting  state  for 
its  presence  to  possess  much  diagnostic  value.'  The  amount  of  fasting 
fluid  that  is  required  to  establish  the  diagnosis  is  an  arbitrary  one, 
variously  estimated  at  from  20  to  100  c.c.  It  is,  however,  generally 
admitted  that  quantities  over  20  to  30  c.c.  if  fairly  constantly  present, 
are  sufficient  evidences  of  the  disorder,  and  the  writer  regards  30  c.c. 
as  the  limit  past  which  a  pathological  condition  begins,  pro^'ided  that 
this  amount  be  repeatedly  found.  Chronic  hypersecretion  cannot  he 
diagnosticated  toith  any  certainty  by  one  examination  alone. 

Two  characteristics  of  the  fluid  are  essential: 


518 


HYPERSECRETION 


1.  Reactions  for  free  hydrochloric  acid  must  be  present.     It  was 
formerly  regarded  essential  that  maltose,  erythrodextrin,  and  proteid 


Fio.   110 


Chronic  hypersecretion.     Fii^tiiiK  content;- 
Fig.   Ill 


Test  breakfast  in  chronic  hypersecretion.  sliowinK  supernatant  excessive  gastric  juice. 

reactions  should  not  be  present,  thus  separating  secretions  from  re- 
tentions, but  this  distinction  is  not  insisted  upon  at  the  ])resent  time. 


CHRONIC  HYPERSECRETION  51!) 

2.  Ill  simple  hypersecretion,  gross  and  recognizal)le  food  remains 
should  not  be  present  in  the  fasting  fluid.  Their  occurrence  takes  the 
condition  out  of  the  hypersecretion  group  and  places  it  in  that  of  pyloric 
stenosis — a  difference  only  perhaps  in  degree,  but  useful  for  clinical 
purposes.  Microscopical  food  remains  are  often,  however,  present,  con- 
sisting chiefl}^  of  undigested  starch  granules  and  finely  divided  carbo- 
hydrate residue,  but  the  quantity  is  so  small  and  the  food  fragments 
so  minute  that  they  are  not  recognizable  as  such  by  the  naked  eye. 

Frequency. — The  frequency  of  the  disorder  depends  on  the  amount 
of  fasting  secretion  that  is  considered  necessary  for  diagnosis.  Boas 
considers  100  c.c.  essential,  although  less  than  this  amount  may  be 
considered  pathological  if  the  clinical  symptoms  of  acidity  and  pain 
be  present.  Reichmann,  who  took  this  view,  that  to  us  appears  to  be 
extreme,  met  with  but  6  cases  in  several  years.  Friedenw^ald  who  has 
adopted  these  requirements  has  encountered  the  ailment  in  but  10  out 
of  1592  patients  examined  (0.65  per  cent.). 

To  insist  upon  so  large  an  amount  of  fluid  being  present  seems  to  the 
writer  to  tend  to  the  exclusion  of  positive  although  minor  degrees  of 
the  ailment,  which  in  justice  to  the  patient  should  be  diagnosticated 
and  treated.  Nor  does  it  seem  necessary  to  insist  upon  the  presence  of 
subjective  symptoms,  as  so  many  and  varied  disorders  run  at  times  a 
symptomless  course,  even  though  demonstrable  evidence  of  disease  be 
present.  Endocarditis  with  well-marked  physical  signs  may  be  safely 
diagnosticated  as  such,  although  dyspnea  and  edema  in  a  given  case 
may  be  absent.  Patients  vary  in  their  susceptibility  to  organic  disease, 
some  suffering  from  a  disorder  that  in  others  is  totally  disregarded. 
It  seems  better  to  rely  for  diagnosis,  therefore,  upon  demonstrable 
evidence  of  hypersecretion  rather  than  to  require  corroboration  by 
the  clinical  symptoms  of  pain  and  distress.  The  writer's  opinion  on 
this  subject  is  held  by  Fenwick,  who,  claiming  that  quantities  over 
20  c.c.  are  sufficient  to  establish  the  diagnosis,  considers  the  complaint 
not  at  all  infrequent.  The  author,  regarding  30  c.c.  or  over  if  fairly 
constantly  present,  to  be  indicative  of  pathological  conditions,  has  found 
the  disorder  in  3.9  per  cent,  of  private  patients  suffering  from  digestive 
disorders,  the  identical  estimate  of  Barclay^  (3.8  per  cent.),  who  includes 
among  his  cases  those  in  which  the  fasting  secretion  was  30  c.c.  or  over. 

Etiology. — After  Reichmann's  classical  paper  in  1882  describing 
the  symptom-complex,  the  view  was  held  that  the  secretory  excess  was 
due  primarily  to  overstimulation  of  the  secretory  nerve  apparatus, 
often  the  result  of  a  pure  neurosis.  Hypersecretion  was  described 
under   the   heading   of   "secretory   neurosis."     Gradually   as   clinical 

»  New  York  State  Jour.  Med.,  July,  1912,  xii,  No.  7. 


520 


HYPERSECRETION 


experience  accuniulated,  it  was  iound  that  motor  insufficiency  could  be 
demonstrated  in  many  instances,  and  that  in  the  majority  of  cases 
ulcer  or  other  organic  lesion  of  the  stomach  was  present,  so  that  little 
by  little  the  theory  of  neurotic  overstimulation  has  been  abandoned, 
although  a  few,  including  Friedenwald,  of  Baltimore  (Osier's  Practice 
uf  Medicine),  still  claim  that  great  mental  anxiety  or  overexcitement 
may  l)e  provocative  of  the  disorder. 

Motor  Error. — ^The  writer  has  no  hesitation  in  stating  that  the  one  and 
only  one  cause  for  hypersecretion  is  a  motor  error  dependent  upon 
spasmodic  or  organic  stenosis  of  the  pylorus  and  that  the  degree  to 
which  fasting  hypersecretion  occurs,  affords  a  reliable  estimate  of  the 
extent  to  which  the  pylorus  has  temporarily  or  permanently  lost  its 
patency.  The  writer's  conclusions  from  a  study  of  his  cases  of  hyper- 
acidity and  hypersecretion  are  as  follows: 

There  are  three  grades  of  motor  insufficiency. 

In  the  first  or  mildest  grade  are  included  atony  and  slight  degrees 
of  pyloric  contraction.  This  group  is  characterized  by  a  hyperacidity 
which  increases  in  direct  proportion  to  the  extent  to  which  the  motor 
error  is  dcNeloped.  Hypersecretion  does  not  occur  in  the  cases  included 
in  this  group. 

Fig.   112 


A  second  group  comprises  cases  in  which  there  is  a  slight  or  moderate 
degree  of  pyloric  stenosis,  either  of  spasmodic  or  of  organic  origin. 
This  group  is  characterized  by  an  increased  hyperacidity  and  an  in- 
creased hypersecretion,  both  proportionate  to  the  degree  of  the  stenosis. 
Atony  is  not  included  as  a  cause  among  these  cases,  as  the  motor 
error  induced  by  it  is  not  sufficient  to  cause  a  fasting  hypersecretion. 

The  third  group  includes  instances  of  well-marked  pyloric  stenosis, 
usually  organic,  occasionally  complicated  by  pylorospasm,  in  which 
hypersecretion  is  combined  by  the  finding  of  coarse  recognizable  food 
remains  in  the  fasting  state.  Hyperacidity  is  observed  on  an  ascend- 
ing scale  as  the  pyloric  lesion  increases  in  the  l)enign  cases,  and  on  a 
descending  scale  in  those  instances  in  which  the  lesion  in  the  pylorus 
is  malignant. 


CHRONIC  HYPERSECRETION  52] 

Rules  without  exception  are  rare,  but  tlie  writer  beliexes  tliat  the 
above  classification  will  be  generally  found  true  in  actual  experience. 
These  three  groups  and  their  characteristic  secretory  disturbance  are 
graphically  illustrated  in  Fig.  112. 

Causes  of  Motor  Error. — ^The  actual  cause  for  the  motor  error  will 
generally  be  found  to  be: 

1.  Ulcer  in  the  vicinit}^  of  the  pylorus  either  on  the  gastric  or  on  the 
duodenal  side. 

2.  Carcinoma  interfering  with  the  patency  of  the  pyloric  canal. 

3.  Reflex  spasm  from  gallstones  or  chronic  apj^endicitis. 

A  protective  spasm  of  the  pylorus  may  occur  as  a  reflex  result  from 
any  irritative  lesion  in  the  midgut  or  its  derivatives,  best  illustrated 
in  gallstones  and  appendicitis,  but  other  lesions,  such  as  pancreatic 
calculus,  cecal  tuberculosis  or  cancer  of  the  appendix,  may  produce 
identical  results. 

Pyloric  Ulcer. — With  ulcer,  pyloric  implantation  seems  to  be  almost 
always  essential  for  hypersecretion,  although  in  rare  instances  ulcer 
at  the  cardia  or  fundus  may  occasion  similar  secretory  excess. 

Fenwick  observed  that  one  of  the  most  severe  clinical  examples  of 
hypersecretion  was  associated  with  ulcer  near  the  cardia.  This  locali- 
zation does  not,  however,  exclude  the  possibility  of  a  grave  motor 
error  either  by  adhesions  or  by  infiltration  and  thickening  of  the 
stomach  wall  sufficient  to  block  peristaltic  waves. 

Amounts  of  fasting  fluid  from  20  to  50  c.c.  were  found  in  50  per  cent, 
of  the  writer's  cases  of  ulcer,  while  in  his  hypersecretions,  gastric  or 
duodenal  ulcer  could  be  positively  diagnosticated  in  IS  per  cent,  of 
the  cases. 

Pyloric  Cancer. — Hypersecretion  wdth  pyloric  cancer  is  more  frequent 
than  ordinarily  supposed,  especially  when  malignancy  invades  the 
walls  and  base  of  a  preexisting  ulcer.  In  18  per  cent,  of  the  writer's 
series  of  cancer,  50  c.c.  or  more  of  a  clear  fluid  giving  hydrochloric 
acid  reactions  were  found  in  the  fasting  state,  and  in  his  series  of 
hypersecretions  cancer  could  be  demonstrated  in  6  per  cent,  of  the 
cases. 

Pyloric  Spasm  Due  to  Gallstones. — Pyloric  spasm  due  to  gallstones 
seems  to  be  most  common  when  one  or  more  stones  are  present  in  the 
gall-bladder  too  large  to  engage  in  the  common  duct,  so  that  a  previous 
history  of  colic  or  jaundice  is  rarely  elicited.  In  the  writer's  series  of 
hypersecretions,  6  per  cent,  were  due  to  the  demonstrable  presence  of 
gallstones. 

Pylorospasm  and  Chronic  Appendicitis. — Pylorospasm  is  a  common 
complication  of  chronic  appendicitis  that  is  usually  otherwise  latent, 
and  it  is  interesting,  as  it  explains  many  of  the  cases  of  hypersecretion 


522  HYPERSECRETION 

in  wliicli  no  lesion  of  the  stomach  or  duodenum  can  be  found  at 
operation.  Before  this  association  was  commonly  known,  many  gastro- 
jejunostomies were  done  without  relief  to  the  patient,  the  after-histor}^ 
clearly  demonstrating  that  a  chronic  appendicitis  was  the  sole  cause 
for  the  original  complaint.  The  writer  cannot  do  better  than  quote 
Fenwick^  in  this  connection: 

"Until  the  year  1907  I  had  felt  convinced  from  postmortem  evidence 
as  well  as  from  the  more  limited  results  aflforded  by  operations  that  88 
per  cent,  of  all  cases  of  chronic  hypersecretion  were  accompanied  by  a 
demonstrable  lesion  of  the  digestive  organs,  while  in  the  remaining 
12  per  cent,  no  disease  that  appeared  to  have  any  connection  with  the 
stomach  could  constantly  be  detected.  I  was,  however,  well  acquainted 
with  a  peculiar  t^pe  of  hypersecretion  in  which  death  frequently  oc- 
curred from  appendicitis,  and  was  in  the  habit  of  warning  such  patients 
of  their  special  liability  to  that  disease;  but  it  was  not  until  an  oppor- 
tunity occurred  in  that  year  of  discussing  the  subject  with  W.  J.  Mayo, 
of  Rochester,  Minn.,  that  the  cause  of  this  appendicitis  and  also  an 
explanation  of  the  12  per  cent,  of  cases  hitherto  unaccounted  for  at 
once  become  apparent.  That  distinguished  surgeon  informed  me  that 
he  had  often  discovered  latent  disease  of  the  appendix  in  persons  who 
seemed  to  require  gastrojejunostomy,  and  that  the  removal  of  the  ap- 
pendix was  followed  by  the  subsidence  of  the  gastric  symptoms  provided 
that  the  alimentary  tract  was  otherwise  healthy.  Furthermore,  that 
several  of  his  earlier  cases  of  gastrojejunostomy  which  had  so  materially 
benefited  by  the  operation  had  subsequently  been  found  to  possess  a 
diseased  appendix  and  that  when  this  had  been  removed  a  cure  had 
resulted.  With  these  facts  in  mind,  the  various  surgeons  who  have 
operated  for  me  on  cases  of  chronic  hypersecretion  during  the  last  two 
years  have  examined  the  appendix  as  well  as  the  other  important 
abdominal  viscera,  and  the  results  obtained  in  112  consecutive  cases 
are  as  follows: 

Chronic  ulcer  of  the  stomach  existed  alone  in  ....  13  cases 
Chronic  duodenal  ulcer  existed  alone  in     ..      .  .46  cases 

Gallstones  existed  alone  in 12  cases 

Disease  of  the  appendix  existed  alone  in    .      .      .  22  cases 

Gastric  and  duodenal  ulcers  coexisted  in    .      .      .  .3  cases 

Duodenal  ulcer  and  gallstones  coexisted  in 3  cases 

Gastric  ulcer  and  diseased  appendix  coexisted  in  .  .5  cases 
Duodenal  ulcer  and  diseased  appendix  coexisted  in  .  .  4  cases 
Cancer  of  the  {)yloru.s  existed  alone  in 4  cases 

112  cases 
'  Lancet,  March  12,  1912. 


CHRONIC  HYPERSECRETION  528 

The  dependence  of  hyi)ersecreti()n  ni)on  an  orj^anic  lesion  of  the  dif^cs- 
tive  organs  appears  to  he  further  corrohorated  hy  the  resuhs  of  treat- 
ment. Thus  in  almost  every  case  where  gastrojejunostomy  was  per- 
formed for  gastric  or  duodenal  ulceration,  and  the  gall-bladder  and 
appendix  were  proved  to  be  healthy,  the  symptoms  of  disordered 
digestion  gradually  disappeared,  and  in  those  instances  that  were  care- 
fully examined  subsequently  by  Paterson  the  hypersecretion  was  found 
to  have  absolutely  ceased.  In  like  manner  the  removal  of  gallstones 
when  other  parts  of  the  digestive  tract  were  healthy  was  followed  by 
a  subsidence  of  the  secretory  disorder,  while  appendectomy,  after  an 
intitial  rise  in  the  percentage  of  the  hydrochloric  acid,  was  usually 
attended  by  similar  results,  although  convalescence  was  sometimes 
unduly  prolonged. 

It  is  difficult  to  estimate  with  any  degree  of  accuracy  the  percentage 
of  hypersecretions  that  are  due  to  chronic  appendicitis,  owing  to  the 
latency  of  its  clinical  course  and  the  absence  of  definite  physical  signs. 
It  is  probable  that  repeated  examinations  might  in  time  indicate  the 
appendicular  origin  of  the  disorder,  but  many  patients  pass  from  ob- 
servation before  it  is  possible  to  arrive  at  any  definite  conclusion. 
In  the  writer's  series  of  hypersecretions,  18  per  cent,  were  due  to  appen- 
dicitis that  could  be  diagnosticated  with  more  or  less  certainty,  while 
in  an  equal  number  of  patients  an  appendicular  origin  could  be  sus- 
pected but  could  not  be  proved.  Chronic  appendicitis  is  probably 
the  most  common  cause  for  hypersecretion  of  mild  degree,  and  ulcer 
for  hypersecretion  of  excessive  degree. 

Pathology. — ^Very  little  is  known  of  the  cellular  changes  in  chronic 
hypersecretion.  Degeneration  of  the  chief  cells  with  normal  preserva- 
tion of  the  border  cells  has  been  observed,  together  with  interstitial 
inflammation  in  varying  stages  of  development.  It  is  not  known 
whether  these  lesions  are  the  cause  or  the  result  of  the  excessive 
secretion.  In  many  of  the  cases  examined  by  Korcynski  and  Jaworski 
no  deviations  from  the  normal  could  be  detected, 

Symptoms. — The  symptoms  are  those  common  to  hyperacidity, 
heart-burn,  and  distress,  but  are  characteristic  in  the  time  of  their 
appearance  in  relation  to  the  meals,  disappearing  for  several  hours 
after  a  meal  is  taken,  depending  upon  the  quality  and  the  quantity 
of  the  food  that  has  been  eaten,  and  then  reappearing  after  the  free  acid 
is  no  longer  neutralized  or  combined  with  the  food,  to  last  until  the 
patient  eats  again.  In  some  instances  the  symptoms  may  appear  onl\' 
during  the  latter  part  of  the  night,  while  others  suft'er  regularly  between 
each  meal.  Distress  before  breakfast  is  characteristic  of  the  disorder. 
Relief  to  the  distress  is  regularly  obtained  by  eating,  by  alkalies,  and 


\ 


524 


HYPERSECRETION 


by  hnajie.    The  relation  of  the  symptoms  to  the  time  of  eating  may  be 
ilhistrated  by  the  accompanying  diagram: 


Fig.  113 


Diagram  showing  time  line  of  pain  and  the  effect  on  it  by  eating,  soda,  and  vomiting — a  three 
days'  record  of  a  case  of  chronic  hypersecretion  complicating  duodenal  ulcer. 


Vomiting  is  not  common  except  during  the  acute  exacerbations  of 
the  disorder.  The  ejecta  consist  of  food  recently  ingested,  together 
with  copious  quantities  of  fluid  acid  so  as  to  scald  the  throat  and  set 
the  teeth  on  edge.  The  longer  after  meals  that  the  vomiting  occurs 
the  fewer  are  the  food  remains  and  the  greater  the  relative  amount  of 
the  acid  fluid. 

The  long-continued  immersion  of  the  mucosa  in  an  abnormally  acid 
secretion  tends  to  excite  a  congestion  of  the  mucous  membrane  accom- 
panied by  interstitial  hemorrhages  and  erosions.  In  the  case  of  erosions 
in  the  ])yloric  portion  of  the  stomach,  traumatism  In'  prolonged  and 
\iolent  pylorospasm  may  play  an  important  part.  These  ulcers  may 
give  rise  to  small  repeated  hemorrhages  or  to  profuse  fatal  hematemesis, 
even  in  the  cases  of  ulceration  which  are  too  minute  to  be  visible  to  the 
naked  eye.  It  is  evident  that  the  symptoms  of  ulcer,  except  those  of 
perforation,  are  due  to  concomitant  hypersecretion. 

Diminished  acidity  of  the  urine  with  ph()sj)haturia  may  occur,  in 
some  cases  apj)areiitly  dei)cndent  ui)on  the  hyi)ersecretion,  but  in  the 
writer's  experience  most  commonly  resulting  from  large  amounts  of 
alkalies  which  the  patient  takes  for  his  distress. 

The  bowels  are  usually  constipated,  although  attacks  of  diarrhea 
nia\'  occur  from  time  to  time. 


CHRONIC  If  YPERSECRETION 


525 


The  extent  of  the  hypersecretion  and  the  severity  of  the  distress  which 
it  produces   are  subject  to  remarkable  fluctuations.     I  nder  judicious 


\^  sot 


Fig.   114 


j% 


<£> 


WEDNESDAY 


Pain  chart  of  hypersecretion  from  chronic  appendicitis. 

treatment,  and  often  without  any  treatment  w^hatever,  the  symptoms 
may  amehorate  and  the  secretion  diminish  so  that  at  times  the  fasting- 
stomach  may  be  empty  or  contain  a  very  inconsiderable  quantity  of 


526 


H  YPERSECRETION 


fluid.  These  remissions  may  last  for  a  number  of  weeks  at  a  time,  during 
which  there  may  be  only  occasional  distress.  The  majority  of  observ- 
ant patients  will,  however,  say  that  they  do  not  remember  having 
been  totally  free  from  discomfort  at  some  time  or  another  in  the  twenty- 
four  hours  for  more  than  two  or  three  days  at  a  time.  The  diagram 
(Fig.  1 14)  shows  the  pain  and  distress  record  of  a  quiescent  case  of  hyper- 
secretion continued  over  a  full  week.  The  writer  would  recommend 
case  records  to  be  kept  by  such  graphic  method  as  this. 


Fig,  115 


-'=^=0 ©    -<}.    ^ 


<±y 


<^ 


M. 


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ti> 


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Voinithiij 


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A 


Tain  fhart  of  a  case  of  chronic  hypersecretion  duo  to  duodenal  ulcer,  continued  for  one  week, 
showing  but  few  completely  free  days. 

Exacerbations  may  occur  either  by  dietetic  error,  by  excessive  phys- 
ical or  mental  fatigue  and  excitement  or  without  any  apparent  cause. 
In  some  instances  the  exacerbations  are  unusually  severe  and  alarming, 
the  symptoms  being  described   under  the  heading  of  "acute  hyper- 


CHRONIC  HYPERSECRETION  527 

secretion."  Some  of  these  severe  exacerbations  subside  within  a  day  or 
so  under  appropriate  treatment,  while  others  continue  with  increasing 
severity  until  the  death  of  the  patient,  unless  relieved  by  a  judicious 
operation. 

Diagnosis. — Gastric  Analysis. — Fasting  Stomach. — The  examination 
may  be  positively  made  by  the  finding  in  the  fasting  stomach  of  a 
watery  fluid  without  admixture  of  gross  food  remains,  that  gives  reaction 
for  free  hydrochloric  acid.  In  mild  cases  proteid,  maltose,  and  erythro- 
dextrin  reactions  are  absent,  but  in  more  marked  instances  of  the  dis- 
order in  which  microscopical  quantities  of  carbohydrate  food  residue  is 
found,  these  reactions  may  be  present.  The  quantity  varies  from  30 
to  100  c.c,  rarely  exceeding  this  latter  amount  unless  accompanied  by 
gross  and  visible  evidences  of  food  stagnation,  or  unless  the  examination 
be  made  during  an  acute  exacerbation  of  the  disorder. 

It  has  been  recommended  that  the  stomach  be  thoroughly  washed 
the  night  before  the  examination  so  as  to  make  it  sure  that  any  fluid 
in  the  fasting  state  the  following  morning  represents  a  secretion  and 
not  a  retention.  The  writer  does  not  regard  this  procedure  at  all  neces- 
sary, for  the  test  is  the  same  whether  preliminary  lavage  is  performed 
or  not.  A  meat  sandwich  and  a  glass  of  water  should,  however,  always 
be  taken  on  the  night  before  the  examination  and  thereafter  nothing, 
not  even  water  is  to  be  allowed,  until  the  tube  is  passed  the  following 
morning  between  8  and  9  o'clock. 

Test  Breakfast. — Examination  of  the  test  breakfast  is  quite  sub- 
ordinate to  that  of  the  fasting  stomach.  The  quantity  abstracted  is 
usually  greater  than  ordinarily  obtained  and  separates  into  two  layers, 
the  supernatant  layer  being  twice  or  more  the  depth  of  that  of  the 
layer  of  sediment.  This  alimentary  hypersecretion  does  not,  however, 
always  occur,  as  the  writer  has  found  in  many  instances  a  normal 
test  breakfast  even  though  30  or  more  c.c.  of  acid  fluid  had  been  present 
in  the  fasting  state.  The  acidity  is  usually  higher  than  normal,  ranging 
from  70  to  110,  the  greater  part  being  due  to  free  acid,  the  proportion 
between  the  free  acid  and  the  total  acidity  being  usually  greater  than 
3  or  4.  The  meat  digestion  is  usually  good,  as  shown  by  an  excessive 
proteid  reaction.  The  digestion  of  starches  is,  however,  poor,  maltose 
reactions  are  weak  or  absent,  while  those  due  to  erythrodextrin  and 
amidulin  are  usually  marked.  In  some  instances  of  extreme  acidity 
blue  reactions  are  obtained  by  the  addition  of  the  iodine  water  to  the 
filtrate.  The  peptic  power  is  usually  greater  than  normal  as  demon- 
strated by  the  Mett  or  the  Hammerschlag  method  of  determination. 
Sarcinffi  are  not  present  unless  food  stagnation  exists. 

Differential  Diagnosis. — The  diagnosis  of  hypersecretion  irrespective 
of  its  cause  is  a  very  simple  matter  and  can  be  made  with  certainty 


528  //  YPERSECRETION 

\)y  the  examination  of  the  fasting  stomach.  The  importance  of  repeated 
examinations  to  establish  the  diagnosis  should  be,  hoMever,  emphasized. 
Hypersecretion  is  but  a  symptom,  and  the  diagnosis  is  not  complete  until 
the  underlying  cause  for  the  ailment  is  discovered.  Severer  types  of  the 
disorder  are  usually  indicative  of  ulcer,  or  of  a  benign  neoplasm  at  the 
pyloric  end  of  the  stomach.  Differential  diagnosis  between  these  two 
conditions  in  the  absence  of  definite  physical  signs  may  be  quite  im- 
possible. Hypersecretion  due  to  chronic  appendicitis  is  ordinarily 
of  a  milder  form  and  less  influenced  by  errors  in  diet.  The  gastric 
symptoms  and  the  amount  of  hypersecretion  show  remarkable  fluctua- 
tions. During  exacerbation  of  the  ailment  the  pain  may  radiate  down- 
ward to  the  middle  or  lower  abdominal  zones,  an  occurrence  which  does 
not  take  place  with  ulcer.  Continuous  dull  ache  or  discomfort  in  the 
epigastrium  lasting  several  days  at  a  time,  and  not  due  to  an  increase  in 
the  h>^persecretion,  points  toward  the  appendicular  origin  of  the  disease. 

Biliary  hypersecretion  consequent  upon  gallstones  or  gall-bladder 
disease  is  often  characterized  b}'  periods  of  complete  intermission. 
When  the  attacks  occur,  howe^-er,  they  are  more  apt  to  be  prolonged, 
extending  over  weeks  or  even  months.  The  pain  may  radiate  to  the 
right  Iwpochondrium  or  to  the  right  side  of  the  back,  suggesting  a 
biliary  origin  for  the  complaint. 

^omiting  is  rare  but  acid  regurgitations  are  especially  common. 
Repeated  examinations  usually  reveal  tenderness  of  the  gall-bladder. 
Complaint  of  pyrosis  may  be  made  from  time  to  time,  but  this  symptom 
is  not  characteristic  except  when  it  occurs  at  a  time  when  the  stomach 
is  empty. 

Prognosis. — The  prognosis  is  that  of  the  primary  cause.  The  symp- 
toms and  the  amount  of  hypersecretion  may  be  modified  by  judicious 
treatment,  but  until  the  radical  cause  be  removed  recurrence  may  be 
expected. 

Treatment. — The  main  treatment  is  that  of  the  exciting  cause. 
Cases  presenting  well-marked  symi)toms  should  be  treated  as  ulcer. 
If  the  symptoms  do  not  improve  by  two  weeks'  trial  of  the  von  I>eube 
treatment  there  is  very  little  use  in  continuing  tlie  cure.  The  question 
of  operation  should  then  arise.  Ulcers  accompanied  by  hypersecretion 
>'ield  less  readily  than  if  the  hyperacid  condition  did  not  exist,  so  that 
operative  interference  is  more  commonly  indicated  in  these  cases. 
Fortunately,  these  ulcers  being  usually  juxtapyloric,  are  very  suitable 
cases  for  surgical  relief.  No  operation,  however,  is  complete  unless 
the  conditions  of  the  gall-bladder  and  especially  of  the  appendix  be 
investigated. 

IIy])ersecr(>tioii  depending  on  cancer  should  be  investigated  surgically 
without  delay,  in  the  h()j)e  that  a  radical  operation  may  be  possible. 


CHROSir  IIYPERSECRKTIOS  520 

The  immediate  result  of  gastrojejunostomy  in  these  eases  is  almost 
always  good,  although  the  operative  risk  is  greater  than  the  similar 
operation  done  for  ulcer. 

Hypersecretion  due  to  gall-bladder  disease  should  be  treated  system- 
atically for  at  least  three  months  by  medical  means  before  the  thought 
of  operation  is  entertained,  provided,  of  course,  that  gall-bladder 
infections  and  obstruction  of  the  bile  ducts  by  the  stone  rlo  not 
occur.  A  prolonged  course  of  Carlsbad  water,  or  small  repeated  doses 
of  sodium  salicylate  with  urotropin,  taken  in  water  as  hot  as  can 
be  sipped,  before  each  meal,  may  be  advised.  Rest  in  bed  with  hot 
applications  over  the  liver  will  often  be  found  serviceable.  If  at  the 
end  of  two  or  three  months  the  symptoms  continue,  the  question  of 
operation  should  then  be  brought  up  and  surgical  advice  requested. 

Hypersecretion  due  to  chronic  appendicitis  should  be  treated  by 
operation  only,  unless  positive  contra-indications  exist. 

Pending  more  radical  treatment  attempts  should  be  made  to  reduce 
the  amount  of  hypersecretion  and  to  relieve  the  symptoms. 

Lavage  though  chiefly  indicated  when  stagnation  is  present  often 
affords  considerable  relief  and  should  therefore  be  tried.  Plain  water 
may  be  used  or  a  dram  of  sodium  bicarbonate  may  be  added  to  the  pint. 
The  writer  has  employed  with  benefit  solutions  of  artificial  Vichy. 
Unless  lavage  prove  beneficial  within  two  or  three  weeks,  there  is  little 
use  in  continuing  it  after  this  time  unless  examinations  of  the  fasting 
stomach  show  a  diminution  in  the  amount  of  secreted  fluid  or  the 
appearance  of  residual  food  remains. 

In  some  cases  a  sufHcent  relief  may  be  obtained  by  passing  the  tube 
in  the  morning  before  breakfast  and  simply  aspirating  the  contents 
of  the  fasting  stomach.  A  similar  aspiration  may  be  performed  just 
before  dinner.  This  removal  of  the  acid  fluid  bj'  aspiration  alone  offers 
no  advantage  over  simple  lavage. 

The  washing  of  the  stomach  with  1  to  3000  solution  of  nitrate  of 
silver  often  proves  of  service. 

The  olive  oil  treatment  commonly  employed  with  pyloric  stenosis 
may  be.  of  service  in  the  cases  supposedly  complicated  by  pylorospasm. 
One  or  two  tablespoonfuls  may  be  given  before  each  meal  or  one  or 
two  ounces  may  be  taken  at  bedtime.  The  washing  of  the  stomach  and 
the  introduction  through  the  tube  of  large  quantities  of  oil,  as  has  been 
recommended,  seems  to  be  carrying  the  oil  treatment  too  far,  as  it 
destroys  the  appetite  and  causes  nausea  and  a  repugnance  for  food. 

The  use  of  alkalies  as  a  symptomatic  treatment  is  almost  inevitable. 
Any  of  the  alkaline  powders  ordinarily  prescribed  may  be  employed 
for  the  purpose,  but  sufficiently  large  doses  should  be  given  to  neutralize 
the  fluid  to  the  extent  of  relieving  the  pain  and  distress. 
34 


530  HYPERSECRETION 

The  use  of  panereon  in  five-grain  doses  between  the  meals  has  seemed 
to  the  writer  of  distinct  service  in  improving  faulty  starch  digestion. 

As  hypersecretion  represents  a  motor  error,  the  overloading  of  the 
stomach  by  large  quantities  of  alkalies  and  mineral  waters  is  to  be 
avoided. 

The  diet  to  be  advised  depends  upon  the  primary  cause  for  the  hyper- 
secretion. If  ulcer  be  suspected  an  ulcer  diet  is  to  be  employed,  the 
writer's  preference  being  decidedly  toward  the  von  Leube  rather  than 
the  Lenhartz  dietetic  treatment. 

In  other  cases  the  diet  should  be  constructed  upon  the  following 
principles:  Frequent  meals  are  always  advisable  so  that  at  no  time 
does  the  acid  fluid  lie  unneutralized  within  the  stomach.  At  least  five 
meals  a  day  should  be  taken.  Starch  digestion  is  usually  interfered 
with,  so  that  this  class  of  foodstuff's  should  be  diminished  and  an 
increase  in  the  fats,  such  as  cream  and  unsalted  butter,  should 
compensate  for  the  caloric  loss. 

The  stimulating  effect  of  beef  juice  and  bouillon  upon  the  gastric 
digestion  should  be  borne  in  mind  and  soups  containing  meat  stock 
and  peptones  should  be  interdicted.  The  red  beefs,  such  as  steaks  and 
chops,  should  be  cut  from  the  diet  owing  to  the  large  amount  of  con- 
nective-tissue framework  which  they  contain  and  their  place  in  the 
dietary  filled  by  fish,  chicken,  or  fowl  of  any  kind  except  goose,  and 
ham  lean  but  not  too  saltv. 


ALIMENTARY    HYPERSECRETION 

Alimentary  or  digestive  hypersecretion  is  a  comparatively  rare  form 
of  disorder  characterized  by  an  excessive  cpiantity  of  gastric  juice 
secreted  by  the  stimulation  of  food  within  the  stomach,  the  phenomenon 
ceasing  when  the  contents  pass  into  the  duodenum,  so  that  the  fasting 
stomach  is  empty.  It  is  evident,  therefore,  that  the  examination  of 
the  fasting  stomach  should  difl'erentiate  this  condition  from  that  of 
chronic  hypersecretion  and  pyloric  stenosis,  in  which  demonstrable 
quantities  of  gastric  juice  are  found  in  the  fasting  state. 

Etiology. — A  certain  degree  of  alimentary  hypersecretion  commonly 
occurs  with  atony  and  gastroptosis.  In  these  examples  of  atonic  error 
the  fasting  stomach  is  empty  or  ])racti('al]y  so,  while  the  test  breakfast 
is  usually  somewhat  more  abundant  than  normal  and  se})arates  on  stand- 
ing into  two  layers,  the  uppermost  li(iui(l  layer  Ix-ing  more  than  equal 
to  but  never  exceeding  twice  the  (le])tli  of  tlic  sedimentary  dei)osit. 
These  cases  while  conforming  to  the  definition  of  alimentary  hyper- 
secretion are  not  included  wjien  the  term  is  used  in  a  clinical  sense. 


ALIMENTARY  HYPERSECRETION  531 

The  term  ''alimentary  hypersecretion"  is  appHed  only  to  those  cases  of 
secretory  excess  in  which  the  aspirated  test  breakfast  is  abnormally 
abundant,  of  this  watery  character,  and  which  separates  on  standing 
into  layers,  the  liquid  layer  being  three  or  more  times  the  depth  of  the 
sedimentary. 

The  nature  of  the  ailment  is  not  understood  at  the  present  time. 
Zweig,  who  with  Caho  made  one  of  the  earliest  contributions  to  the 
subject,  regards  it  as  due  to  abnormal  irritation  of  the  gastric  cells 
not  dependent  upon  motor  error.  According  to  this  observer  the  dis- 
order represents  a  typical  secretion  neurosis.  In  this  view  Zweig  is 
supported  by  Eisner  and  Boas.  Eisner  considers  the  disorder  to  be  a 
nervous  distur})ance  of  secretion,  which  is  almost  exclusively  confined 
to  patients  with  visceral  ptoses  and  who  present  the  stigmas  of  the 
enteroptotic  habitus.  Boas  regards  alimentary  hypersecretion  as  an 
anomaly  which  may  occur  as  a  primary  neurosis  without  an}'  con- 
comitant motor  error.  A  somewhat  different  conception  of  the  disorder 
is  held  by  Strauss,  to  whom  we  are  indebted  for  the  first  clinical  descrip- 
tion of  the  disease.  He  regards  it  probable  that  a  primary  hyperacidity 
exists  which  interferes  with  starch  digestion  to  such  an  extent  that 
undigested  starch  remains  are  retained  longer  than  normal  in  the  stomach 
and  produce  an  increased  secretory  stimulation  of  the  gastric  glands. 
Following  this  acid  outpouring  from  the  gastric  tubules  occur  the 
transudation  of  a  neutral  or  alkaline  fluid  which  neutralizes  in  part  the 
acid  gastric  juice  and  increases  still  more  the  quantity  of  the  liquid 
contents  of  the  stomach.  If  the  "thinning  fluid"  be  unusually  abundant 
the  resulting  admixture  may  be  of  normal  or  even  of  diminished  acidity. 

Whether  Strauss  is  right  in  assuming  that  a  retarded  starch  digestion 
is  essential  for  the  production  of  the  ailment  is  a  doubtful  point,  as 
Zweig  and  Calvo  have  demonstrated  that  alimentary  hj'persecretion 
may  occur  even  after  an  exclusive  diet  of  meat  and  soup.  The  cases 
described  by  Strauss  seem  identical  with  those  reported  under  the  desig- 
nation of  "Lar\'al  Hyperacidity,"  in  which  the  acidity  is  at  its  height 
a  half-hour  after  the  ingestion  of  the  test  breakfast,  diminishing  from 
this  time  on  as  the  thinning  osmotic  fluid  is  poured  out,  the  resulting 
test  breakfast  being  abundant  and  watery  in  the  proportion  of  four 
or  more  parts  of  liquid  to  one  of  sediment. 

It  has  been  attempted  to  differentiate  between  these  cases  of  lar\'al 
hyperacidity  and  alimentary  hypersecretion  by  the  supposition  that 
in  larval  hyperacidity  the  cause  is  to  be  found  in  a  deficient  starch 
digestion,  producing  excessive  flow  of  gastric  juice  and  thinning  fluid 
which  does  not  take  place  after  an  exclusive  diet  of  meat,  while  in 
alimentary  hypersecretion  a  deficient  starch  digestion  is  not  essential, 
so  that  the  excess  of  gastric  juice  rej)resents  a  pure  secretion  unmixed 


0.32  HYPERSECRETION 

with  thiniiinji;  fluid.  In  the  former  condition  the  total  acidity  of  the 
test  brtakfast  is  often  normal  or  below  normal,  whereas  in  the  latter 
form  an  increased  acidity  is  encountered.  This  attempt  to  differentiate 
l)etween  these  two  forms  of  secretory  excess  is  interesting,  but  is  of  no 
practical  value  at  the  present  time.  There  is  no  doubt,  however,  in 
the  writer's  mind  that  when  we  know  more  about  the  thinning  fluid 
and  the  conditions  under  which  it  is  poured  out,  many  obscure  cases 
of  alimentary  hypersecretion  will  be  explained. 

It  is  difficult  to  explain  such  a  case  as  the  following  without  regarding 
the  occurrence  of  an  excessive  flow  of  thinning  fluid  as  probable. 

Yj.  C,  aged  twenty  years,  well-built  athletic  girl,  came  for  diagnosis 
because  of  acne  of  the  face  and  an  undue  sense  of  fatigue  after  riding 
horseback.  There  were  neither  nervous,  gastric,  nor  intestinal  symptoms, 
and  aside  from  a  moderate  anemia  no  physical  evidence  of  disease  could 
be  demonstrated.  The  fasting  stomach  was  regularly  empty;  test 
breakfast  constantly  showed  a  quantity  ranging  from  240  to  230  c.c. 
of  a  watery  consistency,  separating  on  standing  into  two  layers,  the 
supernatant  fluid  being  from  three  to  four  times  the  depth  of  the  sedi- 
ment.   The  total  acidity  was  10,  free  hydrochloric  acid  not  present. 

Many  of  the  writers  agree  that  although  mild  motor  errors  such  as 
atony  may  be  present,  obstructive  motor  errors  are  accompanied  not 
by  alimentary  hypersecretion  but  by  the  chronic  form  in  which  the 
fasting  stomach  contains  acid  fluid.  Nevertheless,  in  two  of  Boas' 
cases  it  was  possible  for  him  to  note  the  transition  of  a  chronic  hyj)er- 
secretion  into  a  pure  alimentary  form. 

Von  Huppert  has  suggested  gastric  ulcer  as  a  cause  for  the  ailment, 
while  Eisner  states  that  in  his  experience  such  an  occurrence  has  never 
been  noted.  In  the  author's  experience  ulcer  has  apparently  been  a 
very  frequent  cause  for  alimentary  hypersecretion.  Owing  to  the  com- 
parati\e  rarity  of  the  ailment  and  the  obscurity  which  envelops  it, 
it  may  not  be  amiss  to  give  the  following  examples  of  cases  apparently 
due  to  these  causes. 

G.  McA.,  aged  fifty-five  years,  was  well  until  twelve  years  ago,  when 
after  several  months  of  distress  in  his  stomach  occurring  several  hours 
after  meals,  he  vomited  a  large  fjuantity  of  blood.  He  was  successfully 
treated  for  ulcer  and  remained  well  until  two  years  ago,  when  he  again 
had  distress  two  hours  after  eating,  lasting  until  he  ate  again.  He  was 
l)ut  on  the  von  Leube  ulcer  cure  and  recovered.  For  the  past  year 
his  only  complaint  has  been  a  slight  feeling  of  distress,  "as  if  he  had 
gas  on  the  stomach"  whenever  he  is  constipated.  Physical  examina- 
tion showed  no  abnormalities.  Fasting  stomach  empty.  Test  break- 
fast 210  c.c,  the  upj)er  licpiid  layer  constituting  nineteen-twentieths  of 
the  entire  meal. 


ALIMENTARY  HYPERSErRETlOX  533 

W.  V.  L.,  male,  aged  twenty-six  years.  Two  \'ears  before  admission 
(levol()i)C(l  ])aiii  in  the  epigastrium,  vomiting,  and  hematemesis.  Was 
in  the  hos})ital  for  six  weeks  on  an  ulcer  cure,  and  then  remained  well 
for  one  year.  A  year  ago  he  de^'eloped  heart-burn  three  or  four  hours 
after  eating,  relieved  by  eating,  for  which  he  desired  treatment.  The 
physical  examination  was  negative.  Fasting  stomach  empty.  Test 
breakfast  190  to  240  c.c,  the  upper  liquid  layer  constituting  nine-tenths 
of  the  entire  bulk.  Total  acidity  ranged  from  100  or  116,  free  hydro- 
chloric acid  90  to  96.  Three  months  later  he  had  a  large  hematemesis 
with  tarry  stools  and  was  again  treated  as  ulcer.  Since  then — a  period 
of  six  years — he  has  had  no  subjective  symptoms,  but  his  alimentary 
hypersecretion  and  high  acidity  have  continued  unchanged. 

A.  S.,  aged  twenty-eight  years.  Two  years  ago  developed  pain  of  a 
burning  character  one  or  two  hours  after  meals,  lasting  until  he  ate  again. 
Occult  blood  present  in  the  stools.  Was  treated  medically  for  duodenal 
ulcer  and  remained  well  until  one  month  ago,  when  the  old  trouble 
returned.  Physical  examination  negative.  Fasting  stomach  empty. 
Test  breakfast  150  to  200  c.c,  the  liquid  layer  constituting  nineteen- 
twentieths  of  the  bulk.  Total  acidity  94  to  120,  free  hydrochloric  acid 
76  to  94.  Patient  was  put  on  a  von  Leube  ulcer  cure  and  the  symp- 
toms ceased,  and  for  the  past  eight  years  have  not  returned.  The 
alimentary  hypersecretion,  however,  continues  as  before. 

Frequency. — The  disease  is  comparatively  infrequent.  Boas  speaks 
of  12  cases  as  comprising  his  series.  Strauss^  states  that  he  has  seen 
over  100  examples  of  the  complaint.  The  writer's  series  embraces  but 
18  indisputable  examples  of  the  disease. 

Symptoms. — Almost  the  entire  literature  of  alimentary  hyper- 
secretion comes  to  us  from  Berlin,  by  Eisner,  Strauss,  Boas,  Zweig, 
and  others.  The  description  which  these  writers  give  of  alimentary 
hypersecretion,  as  they  have  seen  it,  is  so  different  from  that  observed 
by  the  author  that  it  seems  best  to  give  their  views  first  and  then  to 
supplement  their  description  by  that  of  the  cases  which  he  himself 
has  observed. 

The  principal  symptoms  observed  by  Boas  and  others  are: 

1.  A  remarkable  loss  of  weight. 

2.  A  great  variety  of  neurotic  symptoms,  both  general  and  local. 

3.  Obstinate  constipation. 

Emaciation  is  almost  universal,  a  loss  from  10  to  50  kilograms  not 
being  at  all  unusual,  being  only  equalled  by  the  emaciation  of  cases 
with  advanced  motor  errors  and  food  stagnation.  Boas  attributes  the 
loss  of  weight  to  the  loss  of  fluid,  which  he  estimates  at  about  2  liters 
during  the  twenty-four  hours.     Strauss  cannot  explain  the  reduction 

1  Deutsch.  med.  VVoch.,  April  11,  1907. 


534  HYPERSECRETION 

in  weight  l)y  a  loss  of  fluid  from  the  system,  as  owing  to  tlie  infrequency 
of  vomiting  the  fluid  passes  into  the  intestine  and  is  there  reabsorbed. 
On  the  other  hand,  he  attributes  emaciation  to  the  nervous  dread  of 
distress  following  eating,  which  he  has  noticed  in  many  of  his  cases  and 
which  he  terms  "citophobia  dolorosa."  He  rejects  the  possibility  of  the 
lack  of  proper  nutrition  being  caused  by  diminished  starch  digestion 
by  assuming  that  the  intestine  is  capable  of  performing  compensatory 
work.  Xer\-ous  phenomena  seem  almost  always  present  and  are  of  a 
varied  character,  comprising  pressure,  fulness,  eructations,  excessi\e 
flow  of  saliva,  violent  pains,  and  occasional  heart-burn.  Nausea  and 
vomiting  occur  exceptionally. 

Constipation  is  often  so  extreme  that  response  is  difficult  either  b}' 
enemas  or  by  the  most  violent  and  active  medication.  It  is  interesting 
that  according  to  the  German  reports  excessive  phosphaturia,  such  as 
occurs  with  chronic  hypersecretion,  has  not  been  noted. 

The  writer's  experience  in  his  cases  has  not  been  that  of  the  Berlin 
school.  In  none  of  his  cases  was  emaciation  marked,  nor  were  nervous 
phenomena,  either  general  or  local,  in  evidence.  According  to  the 
clinical  history  the  patients  could  be  divided  into  two  groups. 

1 .  The  history  resembled  that  of  gastric  or  duodenal  ulcer,  heart- 
burn, or  distress  appearing  two  or  three  hours  after  eating  at  the  height 
of  the  digestion,  the  length  of  time  after  eating  depending  upon  the 
quantity  and  the  quality  of  the  food.  This  distress  continues  until 
the  stomach  becomes  empty  or  until  the  patient  ate  or  takes  soda.  In 
these  instances  a  differential  diagnosis  from  ulcer  by  the  history  alone 
was  impossible.  Vomiting  was  but  rarely  observed  and  nausea  seldom 
occurred.  The  bowels  were  moderately  constipated  but  could  be  readily 
controlled  by  medication. 

The  intensity  of  the  symptoms  is  proportionate  to  the  height  of  the 
acidity.  Alimentary  hypersecretion  with  diminished  acidity  has  not  in 
the  writer's  experience  given  rise  to  any  form  of  gastric  distress. 

Patients  of  this  group  that  were  treated  as  ulcer  regularly  lost  their 
sj'mptoms  so  that  the  disease  j)assed  into  a  stage  that  could  be  con- 
sidered latent  were  it  not  for  the  characteristic  appearance  of  the 
test  breakfast. 

The  disease  in  the  second  group  of  cases  ran  either  a  latent  course, 
so  that  the  ailment  was  dicovered  only  by  a  routine  examination  of  the 
gastric  contents,  or  the  complaints  a])parently  de])endent  upon  the 
oversecretion  were  slight  and  insignificant.  Occasional  heart-burn 
and  a  moderate  sense  of  fulness  or  distention  were  the  most  frequent 
symptoms  noticed. 

In  this  comparatively  latent  group  are  included  those  in  which  the 
more  active  symptoms  described  in  the  first  set  of  cases  subsided  after 


ALIMENTARY  HYPERSECRETION 


535 


appropriate  treatment.  Some  of  the  cases  so  treated  have  been  fol- 
lowed during  six  or  eight  years  by  perfect  gastric  comfort,  and  during 
this  time  the  patients  have  made  no  complaint  of  their  digestions  and 
considered  themselves  perfectly  well,  although  the  test  breakfasts  still 
show  the  characteristics  of  alimentary  hypersecretion  as  marked  as 
before. 

Diagnosis. — Physical  Signs. — There  are  no  physical  signs  by  which 
the  disorder  may  be  recognized.  Frequent  association  of  alimentary 
hypersecretion  with  gastroptosis  and  the  enteroptotic  habitus  quoted 
by  the  German  authors  was  not  noted  in  the  experience  of  the  writer. 
Succussion  sounds  may  or  may  not  be  readily  elicited  but  possess  no 
diagnostic  value. 

Gastric  Analysis. — Fasting  Stomach. — The  fasting  stomach  is  empty 
or  practically  so,  and  this  point  alone  sharply  differentiates  between 
alimentary  hypersecretion  and  the  continuous  form  which  depends  on 
motor  error. 

Fig.   116 


Test  breakfast  in  alimentary  hypersecretion.  Laj^er  of  liquid  three  times  the  depth  of  the  sediment. 
BreadstufTs  thoroughly  digested.  Moderate  amount  of  pharyngeal  mucus.  The  fasting  stomach  in 
this  case  was  empty.    Measurements  in  centimeters. 


Test  Breakfast. — ^The  appearance  of  the  test  breakfast  is  quite  char- 
acteristic of  the  disorder.    The  bulk  of  the  gastric  quantity  is  excessive, 


530  HYPERSECRETION 

ranging  frequently  from  2()()  to  400  c.c.  and  is  composed  in  large  part 
of  liquid.  On  standing  the  sedimentary  layer  is  seen  to  be  in  depth 
equal  to  that  observed  in  normal  cases,  but  the  supernatant  layer  is 
from  3  to  20  times  that  of  the  layer  of  solids. 

It  is  fair  to  assume  that  alimentary  hx-persecretion  may  be  said  to 
exist  whenever  the  fluid  layer  is  3  times  the  depth  of  that  of  the  sedi- 
ment, provided  that  the  fasting  stomach  be  empty.  The  total  acidity 
varies.  The  majority  of  the  cases  show  a  marked  increase  in  total 
acidity,  often  from  90  to  120,  due  to  the  presence  of  hydrochloric  acid 
in  the  free  and  combined  form.  Proteid  digestion  in  these  cases  is  good, 
even  excessive.  Starch  digestion  on  the  other  hand  is  impaired  so  that 
the  maltose  reaction  is  absent,  while  the  erythrodextrin  and  especially 
the  amidulin  reaction  is  marked.  In  other  cases  the  toal  acidity  may 
be  normal  or  subnormal.  In  one  of  the  writer's  cases  the  total  acidity 
was  but  10.  These  are  regarded  by  the  writer  as  examples  of  excessive 
secretion  of  the  "thinning  fluid"  incompletely  or  completely  neutral- 
izing the  hydrochloric  acid.  When  the  acidity  is  thus  reduced,  starch 
reactions  are  normal. 

In  order  to  demonstrate  that  the  excessive  fluid  represents  a  secretion 
and  not  in  part  a  retention  of  the  liquid  given  with  the  ordinary  test 
breakfast,  Boas  has  recommended  a  dry  test  breakfast  without  any 
water  being  given.  As  the  ordinary  breakfast  roll  contains  35.5  per 
cent,  of  water  he  uses  Albert  biscuits,  which  contain  but  9.8  per  cent, 
of  water.  If  five  Albert  biscuits  are  given  without  water  under  normal 
conditions  the  test  breakfast  is  scanty  and  of  gruel-like  consistency. 
In  alimentary  hypersecretion  from  100  to  200  c.c.  of  gastric  contents 
are  obtained,  showing  on  standing  a  licjuid  layer  three  or  four  times 
the  depth  of  the  sediment. 

Treatment. — In  patients  who  present  ulcer-like  symptoms,  medical 
treatment  is  of  service,  often  totally  relieving  all  sources  for  complaint. 
In  mild  cases  the  treatment  consists  of  lavage  with  silver  nitrate  solu- 
tions, alkalies,  and  diet.  Lavage  with  1  to  3000  solution  of  nitrate  of 
silver  may  be  employed  e\'ery  second  day  and  continued  as  long  as 
apparent  improvement  results.  The  most  convenient  time  for  the 
lavage  is  late  in  the  forenoon  or  in  the  afternoon  before  dinner  at  a  time 
when  residual  food  is  scanty  in  amount  compared  with  the  excess  of 
gastric  juice.  The  solution  may  be  gradually  increased  to  1  to  1000, 
l)ut  should  be  discontinued  temporarily  if  diarrhea  occurs.  Alkalies 
are  of  service  in  reducing  excessive  acidity  and  in  relieving  the  conse- 
quent distre.ss.  Owing  to  the  excessive  liquid  bulk  of  the  gastric  con- 
tents alkaline  powders  are  ])referable  to  alkaliuized  mineral  waters.  A 
"cure"  at  alkaline  mineral  springs  is  contraindicated.  Boas  recommends 
sodium  citrate  in  dram  doses  3  times  a  day  at  the  height  of  digestion. 


ALIMENTARY   II  Y  I'Kh'SKC  RKTJOX  537 

The  diet  (lejxMids  largely  upon  tlic  (|iicsti()ii  of  acidity.  In  Iii<;ii 
acidity  tlie  starclios  should  he  rcchiced  aud  the  fats  and  su(;ars  corre- 
spondingly increased.  Meats  are  ,a;enerally  well  digested,  hut  it  is  })re- 
ferable  to  ])r()liihit  the  red  meats  and  to  rely  on  chicken,  fowl,  ham,  and 
fish.  Bouillon  and  sou])s  containing  meat  stock  should  })e  interdicted. 
There  is  some  dis})ute  as  to  whether  it  is  ad\'isahle  to  allow  three  meals 
a  day  of  a\'erage  })ulk,  or  more  frequent  meals  in  small  quantities. 
The  writer's  j)ersonal  preference  leans  decidedly  toward  frecjuent 
small  meals,  so  that  the  acid  generated  by  the  one  meal  is  combined  with 
or  neutralized  by  the  succeeding  meal  taken  two  or  three  hours  after. 

The  writer  has  employed  belladonna  and  atropine  hoping  to  inhibit 
oversecretion,  but  has  observed  no  beneficial  results  from  their  use. 

Unless  the  symptoms  rapidly  improve  within  a  few  weeks,  it  is  ad\-is- 
able  to  place  the  patient  on  the  regular  von  Leube  ulcer  cure,  giving 
alkaline  powders  whenever  it  is  necessary  to  relieve  distress. 

Under  one  or  the  other  form  of  treatment  above  mentioned  an 
improvement  may  confidently  be  expected  in  the  subjected  symptoms. 
The  patient  may  feel  perfectly  well  and  free  from  all  gastric  distress 
and  may  continue  in  this  state  of  well-being  for  years,  although  examina- 
tions show  that  the  alimentary  hypersecretion  continues  to  the  same 
extent.  In  some  of  these  con\'alescent  patients  the  symptoms  may 
return  with  or  without  apparent  cause  and  then  the  former  treatment 
must  be  resumed  until  the  ailment  becomes  again  symptomless.  The 
writer  has  no  knowledge  of  any  patient  cured  of  this  ailment  by  surgical 
means. 


CHAPTER  XX 
NEUROSES 

In  the  older  treatises  on  diseases  of  the  stomach  many  more  pages 
were  given  up  to  the  description  of  nervous  affections  of  the  stomach 
than  in  books  of  a  similar  character  more  recently  published.  As  medical 
diagnosis  has  perfected  itself,  largely  through  the  experience  gained  bj- 
surgeons  in  abdominal  operations,  various  forms  of  indigestion  formerly 
classed  among  the  neuroses  are  now  shown  to  be  dependent  upon  demon- 
strable organic  disease.  It  is  only  in  the  last  few  years  that  chronic 
appendicitis  even  without  physical  signs  or  the  classical  history  of  defi- 
nite attacks,  has  been  demonstrated  to  be  the  cause  of  a  large  number 
of  gastric  complaints  which  up  to  this  time  were  unexplained  and  for 
that  reason  considered  to  be  of  nervous  origin.  Lesions  of  the  gall- 
bladder have  also  been  placed  upon  a  more  definite  basis  and  have  been 
shown  to  be  the  exciting  cause  for  reflex  disturbances  of  the  stomach 
hitherto  obscure.  Painful  sensations  formerly  described  as  gastralgia 
or  neuralgia  of  the  stomach  are  now  referred  to  gastric  or  duodenal 
ulcer.  Further  instances  of  the  change  in  our  attitude  toward  nervous 
affections  of  the  stomach  might  be  given,  but  the  above  examples  are 
sufficient  to  show  how  accumulating  experience  has  resulted  in  trans- 
ferring many  forms  of  indigestion  from  the  neurotic  group  to  that  of 
definite  organic  disease. 

The  frequency  of  nervous  indigestion  is  impossible  to  determine  with 
any  accuracy  owing  to  the  extreme  difficulty  of  ruling  out  organic 
affections.  This  difficult}^  is  often  intensified  by  the  predominance  of 
nervous  symptoms  in  susceptible  patients  who  are  ill  from  organic 
disease.  Sufficient  time  for  observation,  a  careful  study  of  the  case, 
the  temperamental  susceptibilities  of  the  patient  and  his  reaction  to 
environment  and  oftentimes  repeated  physical  examination,  may  be 
necessary  before  the  diagnosis  is  reached,  and  in  the  meantime  the 
symptoms  are  regarded  tentatively  as  of  nervous  origin.  Many  patients 
pass  so  soon  from  observation  that  sufficient  opportunity  is  not  afi'orded 
for  diagnosis  and  they  are  entered  on  the  case  books  as  instances  of 
nervous  indigestion,  simply  because  that  was  the  first  working  diagnosis. 
A  large  number  of  so-called  nervous  indigestions  occur  with  visceral 
ptoses.  While  there  is  no  doubt  of  the  existence  of  neurasthenic 
dyspepsia  in  these  patients,  they  should  not  be  regarded  as  suffering 
from  nervous  indigestion  alone. 


DIAGNOSIS  OF  NEUROSES  _  539 

The  older  estimates  were  that  50  to  75  per  cent,  of  all  patients  suffer- 
ing from  indigestion  were  examples  of  the  nervous  form.  These  figures 
seem  to  the  writer  altogether  too  high,  even  among  those  classes  in 
the  community  such  as  Polish  Jews  who  are  peculiarly  and  racially 
susceptible  to  neurasthenic  disturbances. 

The  majority  of  the  available  statistics  were  compiled  before  the  era 
of  modern  surgery  and  its  revelations  of  organic  disease  formerly  un- 
suspected. The  writer  estimates  that  in  his  cases  approximately  15 
per  cent,  of  dyspepsias  may  be  regarded  as  of  purely  nervous  origin, 
closely  approaching  the  figures  given  by  Fenwick,  who  found  nervous 
indigestion  in  3  per  cent,  of  his  hospital  cases  and  in  13.2  per  cent, 
of  his  private  series.  An  additional  10  per  cent,  should  be  added  if 
there  be  included  patients  with  the  enteroptotic  habitus  and  well- 
developed  visceral  ptoses. 

Diagnosis. — Although  the  group  of  nervous  diseases  of  the  stomach 
is  a  diminishing  one,  it  is  nevertheless  one  of  the  most  common  sins 
of  diagnosis  to  declare  that  patients  are  suffering  from  nervous  indiges- 
tion when  they  are  really  the  victims  of  organic  disease.  In  some  cases 
this  error  in  diagnosis  is  justifiable,  as  the  mimicrj^  of  disease  may  be 
so  perfect  that  without  an  exploratory  operation  a  definite  diagnosis 
between  organic  and  functional  disorders  cannot  be  made.  In  the  great 
majority  of  instances,  however,  the  error  is  a  culpable  one,  due  to  lack 
of  thoroughness  in  the  examination  of  the  patient,  and  could  have 
been  averted  had  attention  been  paid  to  the  following  rules  for  the 
examination  of  the  case. 

Too  much  reliance  should  not  be  placed  upon  the  patient's  own 
statement  of  his  complaints  without  a  cross-examination  that  might 
bring  out  the  salient  symptoms  of  organic  or  associated  disease.  The 
previous  history  is  frequently  as  important  as  the  narration  of  recent 
events. 

It  is  a  sad  commentary  on  our  diagnostic  methods  that  so  many 
dyspeptics  are  treated  without  there  being  made  at  any  time  a  physical 
examination,  even  of  the  abdomen.  Although  a  careful  physical  exami- 
nation of  the  abdomen  is  essential,  it  is  almost  equally  important  to 
make  an  examination  of  the  heart,  lungs,  and  arteries,  to  examine  blood 
pressure,  the  urine,  and  the  peripheral  reflexes.  The  examination, 
therefore,  should  be  thorough,  complete,  and  repeated. 

There  seems  to  be  a  general  neglect  of  the  importance  of  gastric 
analysis,  or  a  reluctance  on  the  part  of  the  physician  to  force  such  an 
examination  upon  his  patient.  The  writer's  experience  is  that  patients 
are  more  than  ready  to  have  a  test  breakfast  examination  made  if  the 
reason  for  such  a  procedure  is  explained  to  them. 

Before  the  diagnosis  of  nervous  indigestion  is  made  organic  disease 


540  NEUROSES 

must  be  ruled  out  by  a  carefully  taken  history,  by  thorough  and  com- 
plete physical  examination  and  in  the  majority  of  cases  by  examinations 
both  of  the  fasting  stomach  and  of  the  test  breakfast.  To  simplify 
this  exclusion  of  organic  cause  for  the  patient's  complaint  the  writer 
would  suggest  the  following  rules: 

1.  A  diagnosis  of  nervous  indigestion  should  not  be  made  in  any  case 
in  which  the  fasting  stomach  contains  more  than  30  c.c.  of  fluid  gi^'ing 
a  reaction  for  free  hydrochloric  acid.  Hypersecretion  is  a  rudimentary 
form  of  pyloric  stenosis,  spasmodic  or  organic,  and  is  regularly  due  to 
an  organic  and  demonstrable  cause. 

2.  The  diagnosis  of  nervous  indigestion  should  not  be  made  in  case 
of  persistent  hyperacidity  accompanied  by  epigastric  pain.  Nervous 
hyperchlorhydria  may  occur,  but  is  not  accompanied  by  either  heart- 
burn or  pain.  The  association  of  either  of  these  latter  symptoms  should 
suggest  an  organic  origin  for  the  complaint. 

3.  Achylia  may  be  of  nervous  origin  but  is  not  then  accompanied 
by  serious  motor  error.  Achylia  with  food  stagnation  indicates  in  all 
l^robability  cancer  of  the   stomach. 

4.  Achylia  accompanied  by  pain  or  vomiting  indicates  an  organic 
cause  for  the  secretory  disorder,  as  these  symptoms  do  not  occur  in 
the  functional  cases. 

5.  The  diagnosis  of  nervous  indigestion  should  never  be  made  when 
gross  recognizable  food  remains  are  repeatedly  found  in  the  fasting 
stomach.  Under  the  influence  of  mental  shock,  nervous  dread,  excessive 
fatigue,  the  motor  functions  of  the  stomach  may  be  temporarily  abol- 
ished, so  that  food  remains  within  it  for  an  abnormal  period  of  time, 
but  such  a  loss  of  motility  is  temporary  and  cannot  be  demonstrated 
in  succeeding  examinations. 

().  The  diagnosis  of  nervous  indigestion  should  never  be  made  w'hen 
epigastric  pain  recurs  at  a  definite  time  after  eating.  The  old-fashioned 
diagnosis  of  gastralgia  or  neuralgia  of  the  stomach  will  almost  invariably 
be  found  wrong. 

7.  The  diagnosis  of  nervous  indigestion  should  not  be  made  when 
one  symptom  alone  persists  without  other  evidences  of  nervous  insta- 
bility. Nervous  disorders  of  digestion  are  multiform  and  varied, 
irregular  in  character,  and  usually  associated  with  other  general  neurotic 
manifestations.  It  is  improbal)le  that  in  a  patient  of  good  ner\'e  poise 
and  self-control,  one  gastric  symptom,  be  it  nausea,  flatulence,  pain, 
or  distress,  should  persist  day  after  day  without  other  local  symptoms, 
and  without  other  concomitant  evidences  of  a  nervous  disorder.  Such 
a  clinical  course  regularly  im])lies  organic  disease. 

8.  Symptoms  that  might  indicate  a  nervous  disorder  may  be  the 
result  of  drug  addiction,  and  in  doubtful  cases  drug  habits  should  if 


SYMPTOMS  OF  NEUROSES  541 

possible  be  excluded  before  the  complaint  can  be  said  to  be  of  purely 
nervous  origin. 

9.  The  diagnosis  of  nervous  indigestion  should  not  be  made  when 
complaint  is  made  of  indigestion  by  those  over  forty  years  of  age  in 
whom  the  disorder  appears  for  the  first  time.  Those  who  have  passed 
through  the  greater  part  of  the  storm  and  stress  period  of  life  without 
having  shown  their  inability  to  withstand  the  eflfects  of  their  environ- 
ment, are  pretty  well  "seasoned"  as  they  approach  middle  adult  life, 
and  are  examples  of  the  nervous  survival  of  the  fittest.  The  diagnosis 
of  nervous  indigestion  under  these  circumstances  will  almost  invariably 
be  found  to  be  wrong. 

10.  Although  the  existence  of  an  organic  cause  for  the  ailment  may 
be  demonstrated,  it  does  not  necessarily  follow  that  all  the  symptoms 
in  the  case  are  to  be  explained  on  this  basis.  Nervous  people  may  be 
afflicted  by  an  organic  disease,  and  those  with  organic  disease  may  be 
thereby  rendered  weak  and  nervous,  so  that  in  many  cases  organic 
and  nervous  symptoms  are  intermixed  to  form  a  complete  clinical 
picture  that  is  often  quite  confusing. 

The  greatest  assistance  in  unravelling  the  problem  is  rendered  by 
the  presence  of  the  stigmas  of  the  enteroptotic  habitus  in  the  patient. 
Those  with  broad  costal  angle  and  robust  and  well-knit  frame  rarel}' 
suffer  from  prolonged  functional  ailments.  Those  on  the  other  hand 
of  delicate  build,  with  narrow  costal  angle  and  visceral  ptoses  are 
inherently  the  victims  of  a  universal  congenital  neurasthenia  and  are 
almost  regularly  subject  to  functional  disturbances  of  digestion  when- 
ever they  run  down.  Should  organic  disease  attack  such  a  patient  a 
certain  proportion  of  the  symptoms  at  least  are  apt  to  be  of  an 
associated  functional  nature. 

Symptoms. — Nervous  affections  of  the  stomach  have  certain  char- 
acteristics in  common  which  may  be  of  service  in  elucidating  the 
diagnosis. 

1.  The  symptoms  are  shifting  and  variable.  Instead  of  one  symptom 
steadily  predominating  as  in  organic  disease  the  clinical  picture  changes 
almost  from  day  to  day.  There  may  be  nausea  today,  fulness  and  dis- 
tention tomorrow,  and  then  a  comfortable  digestion  for  several  days 
succeeding.  The  variety  in  the  clinical  symptoms  is  suggestive  of 
nervous  disorder. 

2.  The  intensity  of  the  symptoms  may  bear  little  relation  to  the 
character  of  the  food.  The  most  indigestible  assortment  may  be  eaten 
with  relish  and  without  discomfort  while  at  other  times  the  simplest 
food  may  provoke  considerable  distress.  The  lack  of  regular  association 
of  distress  with  the  time,  character,  and  bulk  of  the  meal  is  suggestive 
of  gastric  neurosis. 


542  NEUROSES 

3.  The  symptoms  of  nervous  indigestion  are  often  dependent  upon 
the  nervous  state  of  the  patient,  appearing  during  overexcitement  or 
fatigue  or  accompanying  periods  of  worry  and  apprehension,  and  dis- 
appearing when  the  patient  is  again  hapi)y  and  contented.  In  some 
instances  symptoms  only  appear  before  or  during  the  menstrual  period, 
even  though  that  function  be  normal  in  other  respects.  The  depen- 
dence of  the  symptoms  upon  the  nervous  state  of  the  patient  must  not, 
however,  be  regarded  as  convincing  ])roof  for  the  functional  origin  of 
the  ailment,  as  in  many  organic  diseases  of  the  stomach  the  nervous 
system  bears  an  important  share  in  influencing  the  severity  of  the  com- 
plaint. As  an  extreme  example  may  be  mentioned  instances  of  cancer 
in  which  symptoms,  aggressi\'e  and  severe,  have  disappeared  entirely 
imder  the  influence  of  nervous  or  physical  shock,  or  of  mental  exaltation, 
such  as  that  accompanying  religious  revivals.  It  is  almost  unnecessary 
to  allude  to  the  fact  that  the  symptoms  of  nervous  patients  who  are 
ill  from  any  organic  disease  may  be  greatly  influenced  by  an  underlying 
neurosis. 

4.  Symptoms  that  readily  yield  to  an  antineurotic  treatment  are 
presumably  of  nervous  origin. 

Therapeutic    Tests. — Three  therapeutic  tests  may  be  mentioned. 

(«)  Symptoms  that  readil}'  and  completely  yield  to  small  doses  of 
bromide  are  probably  on  a  nervous  basis.  The  following  prescription 
has  been  found  invaluable  for  the  purpose. 

I^ — Chloral  hydrat 5ss 

Strontii  bromid 5iiss 

Aq.  chloroform 3iv 

Spirits  anisi        gtt.  viij 

M.    Sig. — Teaspoonful  in  water  four  times  a  day. 

A  week's  trial  of  this  prescription  is  of  great  service  in  cutting  out 
from  a  given  case  those  symptoms  that  are  of  a  purely  neurotic  character. 

(b)  A  large  proportion  of  patients  with  nervous  indigestion  are 
suffering  from  chronic  star^■ation,  due  to  insufficient  food.  They  say 
that  they  cannot  eat  more  than  they  do  because  of  distress.  If  in  such 
a  case  the  physician  })e  able  to  gain  the  patient's  confidence  so  that 
a  more  liberal  diet  can  be  gi\en,  and  if  it  can  be  shown  that  sufficient 
and  wholesome  nourishment  ])rodu(es  no  greater  distress  than  the  in- 
valid foods  to  which  the  patient  has  l)een  accustomed,  the  evidence  is 
suggestive  that  the  ailment  is  of  a  functional  character. 

(c)  If  gastric  symptoms  occur  in  a  i)atient  who  is  nervously  run 
down,  and  disapj)ear  by  rest  and  change  of  air  and  scene,  to  reai)i)ear 
later  when  the  actixities  of  daily  life  are  reassumed,  a  functional  origin 
for  the  complaint  may  be  strongly  suspected. 


SENSORY  NEUROSES  543 

5.  Symptoms  of  a  generalized  character  are  of  importance  in  deter- 
mining the  diagnosis.  With  melancholia,  hysteria,  epilepsy,  and  with 
psychoneuroses  of  various  kinds,  concomitant  gastric  symptoms,  in 
the  absence  of  demonstrable  organic  disease,  may  be  considered  tenta- 
tively to  be  of  functional  origin.  Sexual  errors,  such  as  interrupted 
coitus,  masturbation,  and  excesses  of  all  kinds,  are  often  followed  by 
symptoms  of  functional  derangement  of  the  stomach. 

6.  It  must  again  be  emphasized,  even  at  the  risk  of  what  may  be 
considered  reiteration,  that  those  who  inherit  the  enteroptotic  habitus 
are  by  nature  predisposed  to  nervous  indigestion  throughout  their 
lives  whenever  they  overtax  their  nervous  or  physical  strength,  and  the 
existence  of  the  enteroptotic  habitus  is  a  strong  presumptive  proof 
that  the  symptoms  presented  are  in  part  or  in  whole  of  a  nervous  or 
functional  nature. 

The  symptoms  of  nervous  dyspepsia  may  be  di\-ided  into  three 
groups,  according  to  whether  the  functional  error  concerns  sensation, 
motility,  or  secretion.  It  is,  however,  often  impossible  to  draw  a  definite 
line  between  these  three  groups,  as  in  a  given  case  the  symptoms  of 
each  group  may  be  present  so  intermingled  as  to  form  a  confused  clinical 
picture.  Nervous  indigestion  after  all  is  but  the  local  manifestation 
of  a  general  nervous  disorder,  and  the  symptom-complex  is  not  complete 
without  the  presence  of  neurasthenic  or  psychoneurotic  symptoms  that 
may  or  may  not  overshadow  the  local  evidences  of  indigestion.  The 
individual  symptoms  of  nervous  indigestion  may  now  be  described. 


SENSORY  NEUROSES 

Disorders  of  the  Appetite. — Bulimia. — Bulimia,  occasionally  termed 
cynorexia,  consists  of  an  impulsive  and  spasmodic  sensation  of  hunger 
that  cannot  be  resisted.  The  patient  will  suddenly  feel  an  uncontrol- 
lable craving  for  food  and  will  grow  pale  or  may  exen  faint  unless  food 
is  at  once  obtained.  The  craving  is  so  irresistible  that  the  patient  may 
forget  all  conventional  ideas  of  decency  and  will  eat  anything  that 
first  comes  to  hand  and  in  any  place.  One  patient  of  the  writer's  when 
seized  by  this  impulse  would  run  to  the  nearest  ash  barrel  and  eat 
anything  that  he  could  pick  out. 

The  attacks  pass  usually  with  the  first  mouthfuls  taken,  so  that,  as 
a  rule,  an  excessive  quantity  of  food  is  not  required.  There  is,  therefore, 
a  dift'erence  between  polyphagia  or  gluttony  and  bulimia,  although 
the  two  may  be  combined. 

Whether  the  hunger  centre  is  stimulated  centrally  or  peripherally 
is   clinically  quite   unimj)ortant.     The  disorder    usually  occurs   as  a 


A 


544  NEUROSES 

primary  neurosis  in  hysterical  or  epileptic  patients  or  in  those  who  are 
the  victims  of  a  profound  psychoneurosis.  In  rare  instances  bulimia 
has  occurred  as  an  early  symptom  of  brain  tumor. 

Acoria. — Acoria  consists  in  the  absence  of  normal  sense  of  satiety 
after  eating,  so  that  the  patient  never  knows  when  hunger  is  appeased. 
Acoria  may  be  combined  with  anorexia,  so  that  the  patient  may  eat 
without  appetite  but  will  keep  on  eating  without  any  sensation  that 
he  has  eaten  enough.  Acoria  differs  from  bulimia  in  that  there  is  no 
morbid  eagerness  for  eating  as  in  the  latter  condition. 

Anorexia. — Anorexia  is  a  common  symptom  in  many  organic  affec- 
tions of  the  alimentary  tract,  in  many  general  diseases,  such  as  tuber- 
culosis and  nephritis,  and  is  a  common  concomitant  of  nervous  states. 
As  a  symptom  it  has  very  little  diagnostic  value  except  in  those  of  adult 
years  who  without  apparent  cause  show  an  increasing  repugnance  to 
food.    In  these  cases  cancer  of  the  stomach  should  always  be  suspected. 

Nervous  anorexia  may  appear  as  the  result  of  acute  grief  or  nervous 
strain.  The  patient  is  so  overwhelmed  by  his  trouble  that  he  cannot 
eat.  This  is  an  experience  common  to  all.  In  other  instances  the  symp- 
tom is  more  permanent.  The  patient  will  sit  down  to  his  meals  with 
reluctance,  will  pick  at  the  food,  and  will  be  able  to  swallow  a  few 
mouthfuls  with  difficulty.  After  that  he  can  eat  no  more.  It  is  sur- 
prising, however,  how  many  nervous  patients  retain  their  flesh  and 
strength,  though  they  ap])arently  eat  nothing.  This  form  of  anorexia 
must  not  be  confused  with  the  sensation  of  early  satiety,  which  is  a 
symptom  of  gastric  atony.  In  this  latter  condition  the  appetite  is 
usually  good  at  the  beginning  of  the  meal  but  is  easily  a])peased. 

In  the  extreme  cases  of  the  affection,  almost  exclusi\'ely  confined 
to  the  hysterical  and  insane,  the  repugnance  for  food  may  be  so  great 
that  the  ])atient  cannot  bring  himself  to  eat  any  food  at  all.  Loss  of 
weight  may  be  extreme  and  the  ])atient  may  become  a  living  skeleton. 
Recovery  may  take  place  after  weeks  or  even  months  of  inanition  or 
the  patient  may  die  of  starvation  unless  nourishment  be  su.stained  by 
forcible  feeding  through  the  tube. 

Gastralgokenosis. — (iastralgokenosis  (from  yanzf^a/.ys!//.,  gastric  pain, 
and  y-i'.^ii:,  emj)ty)  is  the  term  suggested  by  Boas  to  describe  the  sense 
of  j)ainful  emptiness  of  the  stomach  that  occurs  as  a  pure  neurosis. 
Epigastric  ))aiii  occurs  whenever  the  stomach  is  enijjty  is  relie\ed  at 
once  })y  food.  According  to  iioas  the  symptoms  may  be  permanent  or 
periodic.  The  writer  has  had  no  experience  in  cases  of  this  tyi)e  of  a 
purely  neurotic  character.  In  xarious  neuroses  there  may  be  \ague 
sinkings  in  the  stomach  at  any  time  of  the  da\',  occasionally  but  not 
regularly  relie\-ed  by  eating.  In  many  of  the  writer's  cases  of  chronic 
catarrhal  gastritis  with  normal  acidity,  a  sinking  faintish  feeling  in  the 


SENSORY  NEUROSES  545 

epigastrium  relieved  by  eating,  was  obser\'ed,  but  this  symptom  was 
one  of  vague  discomfort  and  not  of  pain.  It  seems  to  the  writer  that 
the  cases  described  by  Boas  are  probably  instances  of  hunger  pain  due 
to  gastric  or  duodenal  ulcer  or  to  hypersecretion  from  whatever  cause 
it  may  be  induced.  It  has  occurred  in  a  number  of  the  writer's  series 
of  chronic  appendicitis,  disappearing  after  operation. 

Hyperesthesia. — Hyperesthesia  of  the  stomach  may  be  defined  as  a 
condition  of  hypersensitiveness  to  normal  gastric  contents,  so  that 
symptoms  of  distress  will  accompany  digestion,  although  the  stomach 
be  free  of  organic  disease  and  the  secretions  may  be  normal.  In  this 
condition  the  simplest  food  may  cause  distress. 

The  most  common  symptoms  are  fulness  and  a  sense  of  distention 
after  eating,  often  amounting  to  actual  pain.  There  may  be  burning 
sensations  in  the  stomach,  which  we  ordinarily  call  heart-burn,  but 
which  may  not  be  accompanied  by  any  increase  over  the  normal  acidity. 
Indeed,  in  many  instances  in  which  this  complaint  is  made  the  gastric 
contents  may  be  subnormal  or  even  devoid  of  all  acid  whatever.  Par- 
esthesia may  occur,  such  as  a  feeling  as  if  the  stomach  were  being 
scratched  or  that  it  crackled  as  though  it  were  stiffly  varnished.  Nausea 
is  a  common  enough  symptom  and  vomiting  frequently  occurs,  more 
often,  however,  induced  than  spontaneous,  relieving  the  distress.  There 
may  be  the  feeling  of  gas  in  the  stomach,  which  the  patient  attempts 
to  dislodge  in  every  conceivable  way.  The  symptoms  occur  in  attacks 
extending  over  several  days  or  weeks,  often  precipitated  by  periods  of 
nervous  excitement  or  fatigue.  An  unfortunate  result  of  the  ailment 
is  that  the  patient  regards  his  distress  as  due  to  excessive  eating  or  to 
food  which  ferments  or  turns  to  acid,  and  resorts  to  a  diet  that  is  quite 
insufficient. 

The  ailment  is  said  to  be  quite  common  among  nervously  inclined 
individuals,  in  those  addicted  to  the  abuse  of  tea,  coffee,  and  tobacco, 
or  the  victim  of  drugs,  especially  of  opium  and  cocaine.  Nicotine 
poisoning  has  been  said  to  be  an  exciting  cause  for  the  ailment.  It 
may  also  occur  as  a  temporary  phenomenon  after  excess  in  eating  and 
drinking. 

Visceral  sensibility  is  regularly  intensified  in  hypochondriasis  and  in 
irritable  conditions  of  the  central  ne^^■ous  system  that  accompany 
neurasthenia  and  anemia.  Many  cases  of  hyperesthesia  of  the  stomach 
are  difficult  to  explain,  as  it  has  been  proved  that  the  alimentary  tract 
from  the  commencement  of  the  esophagus  to  the  junction  of  the  rectum 
with  the  anal  canal  is  completely  insensitive  to  tactile  stimulation  and 
that  the  mucous  membrane  of  the  esophagus  and  stomach  in  health 
and  in  disease  is  totally  insensitive  to  the  contact  of  acids.  There 
is,  however,  a  sensibility  of  the  lower  end  of  the  esophagus  to  heat 
35 


o4(;  NEUROSES 

and  the  feeling  produced  by  swallowing  hot  fluids  may  be  referred 
entirely  to  the  epigastrium.  The  stomach  itself  is  not  sensitive  to  either 
heat  or  cold.  The  lower  end  of  the  esophagus  is  extremely  sensitive 
to  alcohol,  although  the  introduction  of  concentrated  solutions  of  this 
substance  into  the  stomach  produces  merely  a  sensation  of  warmth. 
Pain  in  the  stomach  may  apparently  be  due  to  hyperacidity,  not  as 
was  formerly  supposed  by  its  burning  effect  upon  the  gastric  mucosa, 
but  by  reason  of  the  increased  peristalsis  which  it  provokes,  raising 
the  intragastric  pressure  and  producing  tension  upon  the  stomach  wall. 
To  cause  pain  this  tension  must  be  rapidly  produced,  otherwise  there  is 
merely  a  sense  of  fulness.  It  is  conceivable  that  in  susceptible  patients 
the  motor  activity  may  be  so  increased  that  painful  or  uncomfortable 
sensations  may  be  produced  by  dilutions  of  hydrochloric  acid  of  a  less 
strength  than  is  normally  present  in  the  gastric  juice.  It  is  a  matter 
of  clinical  observation  that  very  weak  solutions  of  hydrochloric  acid 
will  produce  discomfort  or  pain  in  certain  people  so  that  an  individual 
intolerance  for  acids  has  been  suggested  as  one  of  the  causes  for  ner\'ous 
dyspepsia. 

Clinical  Types. — The  following  clinical  types  of  gastric  hyperesthesia 
may  be  enumerated: 

Fulness  or  gastric  pain  may  follow  meals  that  are  rapidly  eaten. 
The  stomach  is  normally  in  a  state  of  partial  contraction,  or  rather  of 
unrelaxation,  which  we  call  "tone."  To  accommodate  the  bulk  of  a 
meal  there  occurs  a  relaxation  of  the  circular  muscle  fibers  followed  by 
a  gradual  rearrangement  of  these  fibers,  so  that  instead  of  the  stomach 
wall  consisting  of  from  fifteen  to  twenty  layers  in  the  empty  state, 
there  are  but  two  or  three  layers  when  the  organ  is  full.  In  rapid  eating 
intragastric  pressure  rises  before  there  is  sufficient  time  for  the  muscular 
fibers  to  relax  and  so  to  rearrange  themselves  as  to  allow  sufficient 
room  for  the  food.  In  atony  the  muscular  fibers  are  more  or  less  com- 
pletely relaxed  before  the  meal  is  taken,  so  that  any  increased  dilatation 
can  occur  only  through  rearrangement  of  the  nniscular  fibers,  and  as  this 
can  result  only  from  increase  in  intragastric  pressure,  distress  occurs. 

It  is,  therefore,  evident  that  the  more  rai)idly  a  meal  is  eaten  the 
greater  is  the  tendency  toward  fulness  and  discomfort.  A  small  meal 
hastily  boltc'd  will  give  greater  distress  than  a  large  meal  taken  slowly. 
Whenever  relaxation  of  the  muscle  fibers  is  imj)aired, whether  from  ulcer 
or  other  forms  of  infiltration  of  the  stomach  wall,  by  adhesions,  or  by 
refiex  inhibition  of  relaxation  that  may  occur  with  chronic  api)endicitis 
or  diseases  of  the  gall-bladder,  a  sense  of  fulness  and  discomfort  may 
attend  the  taking  of  meals,  even  of  small  size.  It  is  interesting  to 
note  that  the  sensation  of  fulness  ina\"  result  from  the  two  oi)p()site 
(•f)nditions — hyj)ert()inis  and  atony. 


SENSORY  NEUROSES  rA7 

When  air  is  swallowed  slowly  and  naturally,  the  gradual  dilatation 
of  the  stomach  accommodates  the  larji:er  air  bubbles  without  discomfort, 
but  when  gas  in  the  stomach  increases  rapidly  with  hasty  eating  a 
corresponding  relaxation  of  the  muscle  fibers  cannot  occur  soon  enough 
to  obviate  considerable  distress.  A  rapidly  eaten  and  imperfectly 
masticated  meal  regularly  causes  an  increased  peristalsis  with  inhibi- 
tion of  pyloric  relaxation,  caused  by  the  presence  of  hard  masses  of 
food.  The  distress  will  continue  until  the  undigested  particles  are 
softened  and  even  then  an  increase  in  peristalsis  may  be  required 
before  they  can  be  forced  through  the  pylorus.  Relief  naturally  is 
experienced  when  the  stomach  is  emptied  by  lavage  or  by  vomiting. 
The  writer  has  gone  thus  deeply  into  the  affects  of  rapid  eating  and  in- 
sufficient mastication  because  in  his  experience  the  majority  of  patients 
with  so-called  gastric  hyperesthesia  suffer  from  the  mechanical  effects 
of  their  mode  of  eating.  It  is  hardly  fair  to  describe  these  errors  as 
nervous  indigestion. 

There  are  patients  who  are  peculiar!}'  sensitive  to  hot  fluids  and  cer- 
tain kinds  of  food  and  drink.  Soup,  tea,  and  coffee  must  be  cooled  before 
they  can  be  taken  without  discomfort,  and  if  taken  too  hot  there  results 
a  burning  feeling  running  down  the  esophagus  to  the  stomach  instantly 
relieved  by  sipping  cold  water.  Fluids,  syrups,  and  acid  vegetables, 
such  as  tomatoes,  will  produce  the  same  result.  Alcohol  will  almost 
regularly  precipitate  an  attack,  especially  the  more  concentrated 
beverages,  such  as  sherry,  brandy,  Madeira,  and  the  cordials. 

The  symptoms  of  this  group  seem  to  be  produced  by  irritation  of  the 
lower  portion  of  the  esophagus  rather  than  by  irritation  within  the 
stomach  itself.  This  view  is  supported  by  Hertz's  experiments  showing 
that  painful  sensibility  of  the  lower  end  of  the  esophagus  may  occur  by 
thermal  and  alcoholic  irritation  and  by  the  fact  that  even  teaspoonful 
doses  of  cold  water  will  immediately  alleviate  the  distress. 

This  form  of  hyperesthesia  in  the  writer's  experience  is  regularly 
due  to  one  of  two  causes  and  can  therefore  be  hardly  considered  a  true 
neurosis. 

In  the  majority  of  instances  the  symptom-complex  accompanies 
gallstones  or  irritative  lesions  of  the  gall-bladder.  The  writer  has  seen 
a  number  of  cases  in  which  the  symptom  has  disappeared  after  the 
passage  of  gallstones  or  after  the  gall-bladder  has  been  drained.  The 
following  history  will  illustrate  this  point: 

G.  H.,  aged  forty-seven  years,  was  practically  free  from  indigestion 
until  he  had  typhoid  fever  twelve  years  ago.  Since  that  time  he  has 
complained  of  recurring  attacks  of  })ain  and  tenderness  over  the  gall- 
bladder with  nausea  and  vomiting,  each  attack  lasting  about  twenty- 
four  hours  and  then  reap})earing  after  an  interval  of  several  weeks. 


548  NEUROSES 

Between  the  attacks  there  has  been  at  times  a  dull  aching  pain  of  the 
liver  running  to  the  back.  During  these  twelve  years  the  patient  has 
been  unable  at  any  time  to  take  soup,  tea,  or  coffee  unless  lukewarm. 
Liquids  hotter  than  this  as  well  as  the  more  concentrated  forms  of  alcohol 
will  produce  an  immediate  burning  pain  running  from  the  throat  to  the 
stomach  instantly  relieved  by  hot  water,  so  that  at  his  meals  he  has  to 
sip  cold  water  frequently  to  relieve  his  distress.  This  symptom^  con- 
tinued until  the  gall-bladder  was  drained  and  8  ounces  of  mucopurulent 
fluid  and  a  number  of  gallstones  were  evacuated.  Since  then  he  has 
been  totally  free  from  his  complaint. 

In  other  instances  gastric  or  esophageal  hyperesthesia  is  dependent 
upon  gout,  and  the  symptoms  will  continue  until  relieved  by  appropriate 
treatment.  It  is  suggestive  in  these  cases  that  the  throat  is  the  most 
sensitive  and  shows  the  characteristic  appearance  of  gouty  pharyngitis. 

Gastralgia. — "Gastralgia"  or  pain  in  the  stomach  and  "epigastralgia" 
or  pain  referred  to  the  epigastrium  are  terms  used  to  describe  painful 
sensations  in  the  upper  part  of  the  abdomen.  The  term  "gastralgia" 
is  an  unfortunate  one,  as  it  implies  that  pain  arises  in  the  stomach  itself, 
but  it  has  been  sanctioned  by  usage  so  as  to  indicate  merely  that  the 
pain  is  referred  to  the  neighborhood  or  region  of  the  stomach.  It  is 
in  this  broader  sense  that  the  writer  employs  the  term. 

Gastralgia  was  formerly  regarded  as  a  frequent  complaint  occurring 
in  periodical  attacks  quite  independent  of  any  organic  disease.  Attacks 
have  been  described  of  great  severity.  The  patient  will  be  suddenly 
seized  with  a  burning,  boring,  tearing,  or  lacinating  pain,  originating 
in  the  epigastrium  and  radiating  in  various  directions.  The  face  is 
anxious  and  drawn,  the  pulse  rapid  and  thready,  the  temperature 
subnormal.  Faintness  may  occur  or  the  patient  pass  into  a  mild  form 
of  collapse.  The  seizure,  however,  ceases  somewhat  abruptly  and  re- 
covery is  uneventful  until  another  paroxysm  occurs.  A'omiting  and 
repeated  retching  are  not  infrequent.  The  writer  is  extremely  skeptical 
as  to  the  occurrence  of  paroxysms  of  this  severity  that  can  be  considered 
of  a  neurotic  character.  There  is  no  doubt  that  epigastric  pain  may 
occur  as  a  pure  neurosis  in  nervous  or  hysterical  patients,  but  the  pain 
is  rarely  severe,  is  not  limited  to  the  epigastrium,  but  occurs  in  other 
parts  of  the  body,  showing  a  general  neuralgic  condition. 

Occurrence.  —  Before  we  are  warranted  in  assuming  that  a  i)ain 
referred  to  the  stomach  is  nervous  we  must  rule  out  all  organic  diseases 
of  the  stomach,  such  as  ulcer,  adhesions,  or  ])yl()ric  stenosis  that  are 
regularly  accompanied  by  paroxysms  of  pain,  acute  appendicitis,  the 
gastric  crisis  of  tabes,  biliary  colic,  angin'a  abdominalis,  epigastric 
licrnia,  and  inguinal  hernia  that  is  due  to  a  patulous  condition  merely 
of  the  internal  ring.     The  possibility  of  lead  j)oisoning  must  also  be 


SENSORY  NEUROSES  549 

considered.  Alalaria  may  give  rise  to  recurring  epigastric  pain  often 
with  A'omiting,  wiiicli  usually  marks  the  onset  of  the  paroxysm,  'i'he 
pain  is  rarely  limited  to  the  epigastrium,  usually  difi'using  over  the 
abdomen.  Cabot'  states  that  in  a  single  week  of  service  in  the  Massa- 
chusetts (jeneral  Hospital,  three  patients  were  sent  in  to  be  operated 
on  for  supposed  appendicitis.  All  had  malarial  fever  and  all  were 
promptly  cured  by  quinine.  In  some  cases  of  uremia,  upper  abdominal 
pain  may  be  observed  which  may  be  entirely  located  in  the  epigastrium 
and  which  may  precede  uremic  convulsions.  The  late  Dr.  J.  H.  Musser^ 
reported  a  case  of  uremia  with  vomiting  and  abdominal  pain.  The 
autopsy  showed  the  pain  could  not  be  accounted  for  by  any  abdominal 
condition  and  was  evidently  toxic.  It  is  not  improbable,  however, 
that  in  the  uremic  cases  erosions  or  ulceration  may  be  the  cause  for 
the  pain. 

Epigastric  pain  appearing  whenever  the  patient  walks  after  eating, 
is  characteristic  of  arteriosclerosis,  although  the  identical  phenomenon 
may  also  be  observed  with  perigastric  adhesions. 

A  constantly  recurring  epigastric  pain  without  other  manifestations  of 
disease  should  never  be  considered  of  nervous  origin  but  should  regu- 
larly suggest  a  dependence  upon  an  organic  lesion.  When  all  the  above 
causes  for  pain  have  been  excluded  there  remains  but  a  small  number 
of  patients  whose  pain  may  be  considered  of  neurotic  origin. 

Insane  and  Feeble-minded. — Epigastric  pain  is  frequently  observed 
among  insane  and  feeble-minded  patients  and  may  closely  simulate 
organic  disease  of  the  stomach.  The  assumption  that  the  epigastralgia 
is  dependent  upon  the  psychosis  would  be  unwarranted  were  the  patient 
of  normal  mentality. 

Chlorosis.  —  Chlorosis  generally  accompanied  by  constipation  may 
be  the  cause  for  sudden  or  nagging  epigastric  pain,  sometimes  coming 
immediately  after  meals,  sometimes  later.  The  pain  may  not  always 
remain  in  the  epigastrium  but  may  shift  to  the  lower  abdomen,  chest, 
or  back.  Some  of  these  patients  show'  hyperacidity  while  others  do 
not,  so  that  the  pain  cannot  be  said  to  depend  upon  the  degree  of 
gastric  acidity. 

A  course  of  iron  and  saline  laxatives  will  result  in  a  speedy  and 
uneventful  recovery.  The  writer  has  seen  a  number  of  these  cases, 
but  regards  them  far  less  common  than  ordinarily  supposed. 

Syphilitic  Disease. — Gastralgia  may  occur  in  syphilitic  patients  due 
to  depreciation  of  their  general  condition  rather  than  to  any  sec- 
ondary or  tertiary  lesion.  These  cases  are  commonly  seen  in  hospital 
practice  and  are  readily  relieved  by  antisyphilitic  treatment. 

»  Differential  Diagnosis,  p.  140.  -  Amer.  Med.,  March  2G,  1910. 


550  NEUROSES 

Hyperesthesia. — Epigastric  pain  may  occur  in  those  with  apparently 
normal  digestion  as  the  result  of  the  so-called  hyperesthesia  of  the 
stomach.    These  cases  are  described  on  page  545. 

Pneumatosis  Ventriculi  and  'Aerophagia. — Epigastric  pain  as  a 
neurotic  manifestation  may  occur  with  pneumotosis  ventriculi  and 
aerophagia,  and  is  elsewhere  described. 

Pain  in  the  epigastrium  is  a  common  symptom  in  heart  disease  during 
the  period  of  decompensation  and  is  due  to  congestive  swelling  of  the 
liver.  Anorexia  and  vomiting  are  frequently  concomitant  symptoms. 
The  frequency  of  this  form  of  pain  in  hospital  cases  is  shown  in  the 
accompanying  table  from  Cabot. ^ 

Causes  of  Epigastkic  Pain 

Gastric  and  hepatic  congestion  due  to  cirrhosis  or  cardiac 

disease 898  cases 

Appendicitis 350  cases 

Peptic  ulcer 

Gallstones 

Hyperchlorhydria 

(Many  of  these  cases  may  actually  be  cases  of  peptic 
ulcer.    Only  operation  or  autopsy  can  decide.) 

Gastric  cancer 

Pericarditis 

Gastric  neurosis 

Pancreatitis 

Pyloric  adhesions 

Angina  abdominalis 

Molent  abdominal  pain  may  occur  with  diabetes,  and  may  occur 
in  the  form  of  an  abdominal  crisis  preceding  coma.  Downes  and 
O'Bien^  reported  two  cases  of  diabetes  in  which  an  abdominal  crisis 
occurred  with  pain,  vomiting,  and  abdominal  rigidity,  suggesting  to 
two  or  three  observers  the  necessity  for  operation. 

Severe  attacks  of  epigastric  pain  may  occur  in  those  addicted  to 
morphine  or  cocaine,  and  these  drug  addictions  should  regularly  be 
suspected  in  doubtful  cases  of  apparent  neurotic  origin. 

Flatulence. — A  certain  amount  of  air  is  always  present  in  the  healthy 
stomach  contained  within  that  portion  of  the  fundus  which  lies  above 
the  cardiac  orifice,  forming  an  air  chamber  known  to  the  radiologists 
as  the  "magenblase."  Chemical  examinations  shows  the  contents 
of  the  air-bubble  to  be  composed  of  ordinary  atmosi)heric  air  which 
has  been  swallowed  with  each  muscular  effort  at  deglutition  either 
during  the  meals  or  between  meals  with  th(>  sali\a. 

'  Differential  Diagnosis,  1911. 

-  Intercolonial  Medical  Journal,  Austmlasia,  Scj)! ember,  1909. 


347 

cases 

329 

cases 

326 

cases 

133 

cases 

88 

cases 

72 

cases 

7 

cases 

2 

cases 

1 

case 

SENSORY  NEUROSES  551 

There  is  undoubtedly  possessed  by  the  stomach  a  certain  aspirating 
power  so  that  air  is  sucked  into  the  organ  by  the  alternate  contraction 
and  relaxation  of  its  wall,  hut  the  amount  of  air  thus  introduced  is 
small  compared  with  that  entering  with  deglutition. 

Etiology  and  Symptoms. — Ordinarily  no  symptoms  are  produced  by 
the  average  amount  of  air  contained  in  the  "magenblase,"  although 
occasionally  hypersensitive  or  imaginary  individuals  claim  that  they 
are  distressed  by  flatulence  and  constantly  attempt  in  every  conceivable 
way  to  relieve  themselves,  although  physical  examination  or  radio- 
graphs may  show  the  amount  of  gas  to  be  practically  negligible. 

Increased  amounts  of  air  may  be  introduced  by  too  freciuent  attempts 
of  deglutition,  such  as  with  salivation,  nervous  habits  of  aimless  swal- 
lowing, irritable  conditions  of  the  throat  and  acid  feelings  in  the  stomach. 
The  chewing  of  tobacco  and  hasty  eating  of  unmasticated  food  are 
frequent  causes  for  excessive  accumulations  of  gas. 

When  air  is  gradually  introduced  into  the  stomach,  relaxation  and 
rearrangement  of  the  muscular  fibers  may  allow  the  organ  to  adapt 
itself  to  the  increased  volume  of  its  contents,  so  that  intragastric  pres- 
sure is  not  unduly  raised,  and  consequently  no  great  distress  is  experi- 
enced. When,  however,  the  gaseous  volume  is  rapidly  increased,  fulness, 
distress,  and  even  pain  may  be  produced  before  the  stomach  is  able 
sufficiently  to  dilate.  Rapid  eating  is  one  of  the  commonest  causes 
for  gastric  flatulency.  Lack  of  adaptation  of  the  stomach  to  its  con- 
tents occurs  with  infiltration  of  the  wall  by  inflammatory  tissue  or 
malignant  growths,  or  with  perigastric  adhesions,  so  that  with  ulcer, 
cancer,  and  adhesions  a  moderate,  even  a  normal  quantity  of  gas  may 
occasion  severe  distress. 

Hypertonus,  such  as  occurs  with  gallstones,  cholecystitis,  and  chronic 
appendicitis,  may  likewise  produce  painful  sensations  of  fulness  and 
distention  even  though  the  actual  amount  of  gas  be  not  excessive. 

Flatulence  is  favored  by  the  opposite  condition  of  hypertonus,  and 
is  a  regular  accompaniment  of  atony  and  of  atonic  gastroptosis,  con- 
stituting the  most  constant  symptom  of  these  ailments.  The  atonic 
gastric  wall  allows  the  stomach  to  be  easily  inflated.  The  bulk  of  the 
gas  naturally  depends  upon  the  pressure  to  which  it  is  exposed,  and  as 
the  reduction  in  pressure  allows  it  to  increase  in  bulk,  the  air-bubble 
or  "magenblase"  in  atony  is  regularly  larger  than  normal. 

The  amount  of  gas  is  regularly  most  ^•oluminous  in  the  atonies  that 
are  accompanied  by  hyperacidity,  probably  because  of  the  instinctive 
desire  to  neutralize  the  acid  by  swallowing  saliva  and  the  consequent 
pumping  in  of  air.  The  gaseous  distention  is  furthermore  increased  by 
the  carbon  dioxide  that  is  liberated  whenever  the  patient  takes  soda. 
A  relaxed  atonic  stomach  cannot  readily  expel  the  gaseous  contents  and 


552  NEUROSES 

hence  there  results  an  increasing  accumulation.  The  occurrence  of 
extreme  distention  accomj)anying  ])aretic  conditions  of  the  stomach 
has  been  described  in  full  under  acute  dilatation. 

Whene\'er  intragastric  pressure  is  raised  either  b}'  accumulation  of 
gas,  or  by  an  increased  pressure  upon  the  contents,  a  sense  of  fulness 
or  distention  is  experienced,  which  is  attributed  by  the  patient  either 
to  overeating  or  to  "fermentation"  of  food.  The  natural  tendency  is 
for  the  patient  to  restrict  himself  to  a  diet  that  is  often  quite  insufficient 
for  the  maintenance  of  health  and  nutrition  and  to  limit  his  dietary 
to  articles  of  food  that  are  not  readily  fermentable.  A  popular  mis- 
conception is  that  if  the  eructated  gas  bear  the  odor  or  taste  of  food  that 
has  been  eaten,  the  proof  is  convincing  that  the  food  is  not  properly 
digested,  and  so  one  article  after  another  is  cut  out  from  the  menu.  As 
long  as  any  seasoned  or  flavored  food  remains  in  the  stomach,  just  so 
long  will  the  gas  that  is  raised  carry  the  flavor  upward.  It  is  only  when 
abnormal  odors  are  detected,  such  as  hydrogen  sulphide  or  the  rancid 
odor  of  butyric  fermentation,  or  when  the  ordinary  flavors  of  ingested 
food  are  repeated  long  after  the  stomach  should  be  empty,  that  the 
symptom  demands  investigation. 

Flatulence  is  a  common  symptom  of  cardiac  disorders  during  the 
stage  of  decompensation.  Fulness  and  distention  occur  after  meals, 
and  the  accumulation  of  gas  interferes  with  the  descent  of  the  diaphragm 
and  occasions  dyspnea,  palpitation  and  irregularity  in  the  heart's  action. 
Anorexia  often  to  the  point  of  food  loathing  is  commonly  present  and 
vomiting  due  either  to  venous  engorgement  of  the  stomach  or  to  in- 
judicious medication  may  be  repeated  and  difficult  to  control.  Pain 
caused  l)y  enlargement  of  the  li\er  is  added  to  the  symptom-complex 
so  commonly  observed  in  our  hospital  wards. 

Flatulence  frequently  occurs  with  constipation  and  is  relie\'ed  when 
the  bowels  are  opened,  but  in  these  cases  intestinal  distention  precedes 
the  gastric  distress. 

(raseous  accumulations  may  be  ])roduced  by  either  carbohydrate 
fermentation  or  ])roteid  decomposition,  but  the  gases  are  generated  so 
slowly  that  sufficient  time  is  allowed  for  the  stomach  to  adapt  itself 
to  the  increased  bulk  and  but  little  distrsss  ordinarily  ensues.  Fer- 
mentation, moreover,  rarely  produces  a  sufficient  volume  of  gases  to 
be  a  disturbing  factor.  The  odor  and  taste  of  the  eructations  may 
be  exceedingly  unpleasant  and  may  create  a  loathing  for  food,  but 
the  feeling  of  fulness  or  distention  is  but  rarely  experienced. 

An  appreciable  fermentation  occurs  only  with  grave  motor  errors, 
usually  due  to  pyloric  stenosis,  and  owing  to  the  inhibitory  eft'ect  of 
hydrochloric  acid  upon  fermentatiNc  processes,  more  common  in  the 
malignant  cases. 


SENSORY  NEUROSES  :)')'^ 

The  term  "fermentation"  is  uiifortiuiately  aj)i)lied  to  any  or  all 
forms  of  gastric  flatulence,  and  patients  are  (jverdieted  accordingly 
and  restricted  in  their  choice  of  food.  The  diagnosis  of  "fermentation" 
in  the  al)sence  of  grave  motor  error  is  almost  in\'ariably  hased  upon 
misapprehension  of  facts  and  almost  invariably  wrong. 

Nervous  Flatulence. — Nervous  flatulence  may  occur  temporarily 
from  many  causes,  such  as  mental  shocks  or  emotional  out})ursts,  hut 
is  rare  as  a  more  permanent  phenomenon  except  in  enteroptotic  indi- 
viduals with  gastro-intestinal  atony.  The  cause  for  the  acute  flatulence 
is  probabl}'  a  suddenly  induced  atony  of  nervous  origin. 

Sudden  sharp  attacks  of  flatulence  may  occur  in  ner\'ous  pregnant 
women  who  never  vomit  during  the  period  of  gestation.  The  ailment 
usually  appears  in  short,  sharp  attacks  ordinarily  induced  by  fatigue, 
excitement,  or  mental  shock.  The  attack  is  ushered  in  by  oppression 
in  the  chest,  and  distention  of  the  epigastrium  which  later  becomes  more 
generalized  so  that  the  entire  abdomen  is  distended,  tense,  and  tender. 
Eructations  of  odorless  gas  in  large  quantities  and  the  expulsion  of  flatus 
are  followed  by  temporary  relief  only,  as  the  gas  seems  rapidly  to  accu- 
mulate. The  attack  may  last  for  from  several  hours  to  one  or  two  days, 
and  often  subsides  somewhat  abruptly,  although  considerable  soreness 
of  the  abdomen  may  persist  for  several  days.  Subsequent  paroxysms 
may  recur  at  intervals  of  one  or  more  weeks.  In  other  cases  the  flatu- 
lence is  more  or  less  continuous  and  merely  varies  in  degree  from  time 
to  time,  although  the  exacerbations  are  rarely  sufficiently  se^'ere  to 
occasion  more  than  an  average  amount  of  distress. 

Aerophagia. — Nervous  eructations  or  aerophagia  comprise  a  group 
of  cases  with  well-marked  clinical  symptoms  that  are  quite  distincti\e. 
The  disorder  consists  in  the  involuntary  swallowing  of  air  that  is  imme- 
diately eructated  with  a  loud  and  explosive  noise.  Gas-bubbles  ascend 
the  esophagus  and  burst  in  the  pharynx  with  explosive  force,  one  after 
another,  often  with  almost  incredible  rapidity,  occasionally  every  few 
seconds.  Ordinarily,  however,  single  eructations  occur  and  are  repeated 
at  intervals  of  from  five  to  fifteen  minutes.  The  paroxysms  cease  during 
sleep,  but  persist  during  the  meals,  and  are  often  brought  on  or  inten- 
sified by  anger,  emotional  outbreaks,  or  by  visits  from  unsympathetic 
friends.  An  attack  may  often  be  precipitated  by  examination  of  the 
throat  or  by  palpation  of  the  epigastrium  during  the  routine  examina- 
tion of  the  patient.  The  amount  of  gas  brought  up  on  each  occasion 
is  quite  small — its  constituency  is  that  of  atmospheric  air. 

The  essential  feature  of  the  ailment  consists  of  a  clonic  spasm  of  the 
pharynx  which  forces  air  involuntarily  into  the  esophagus,  and  which 
is  easily  detected  by  placing  the  fingers  upon  the  upper  portions  of  the 
neck  during  a  paroxysm.    The  greater  bulk  of  the  air  does  not  usually 


554  NEUROSES 


reach  the  stomach,  but  is  contained  in  the  esophagus  before  it  ascends, 
although  in  many  instances  some  air  certainly  does  enter  the  stomach 
and  is  heard  as  a  loud  and  distinct  bruit  or  bursting  sound  following 
the  pharyngeal  spasm  when  the  stethoscope  is  placed  over  the  epigas- 
trium. In  rarer  instances  pharyngeal  contractions  may  force  air  into  the 
stomach  in  greater  quantities  than  can  be  dislodged  upward,  so  that 
the  stomach  becomes  rapidly  inflated.  This  condition  is  often  known 
as  pneumatosis  ventriculi.  Gas  may  even  pass  from  the  stomach  into 
the  intestines  so  that  general  abdominal  tympany  results. 

In  some  cases  nervous  eructations  occur  in  short  but  recurrent  attacks, 
some  of  which  are  mild  though  annoying  both  to  the  patient  and  to 
those  in  the  immediate  neighborhood,  while  in  others  the  eructations 
are  excessive  and  the  attacks  so  prolonged  that  the  patient  becomes 
quite  worn  out.  The  attacks  may  be  separated  by  fairly  long  intervals, 
or  the  paroxysms  may  run  together  so  that  the  disorder  becomes  more 
or  less  permanent,  and  exceedingly  rebellious  to  treatment. 

Vomiting. — Vomiting  can  only  be  considered  a  symptom  of  nervous 
dyspepsia  when  all  forms  of  organic  disease  that  may  produce  the  symp- 
tom can  be  excluded  from  the  diagnosis.  Nervous  vomiting  must  be 
distinguished  from  regurgitation  of  foofl  which  is  ejected  whene\'er  it 
reaches  the  mouth.  It  is  impossible  to  do  more  than  briefly  allude 
to  a  few  of  the  more  ordinary  organic  causes  for  vomiting  which  are  to 
be  considered  as  possibilities  in  any  given  case. 

Etiology. — Organic  diseases  of  the  stomach  are  frequently  accompanied 
by  vomiting.  Vomiting  of  acid  watery  fluid  or  of  ancient  food  remains 
are  readily  referred  to  an  organic  cause.  Erratic  vomiting  may  usher 
in  the  symptoms  of  chronic  ulcer  or  cancer,  so  that  for  a  time  the  diag- 
nosis may  remain  in  considerable  doubt.  Persistent  vomiting  having 
many  of  the  characteristics  of  the  ])urely  neurotic  type  may  occur 
with  chronic  appendicitis.  Irregular  and  often  unj)remeditated  vomit- 
ing is  not  uncommon  with  gallstones  e\en  though  they  be  otherwise 
latent. 

Reflex  vomiting  may  originate  from  various  irritative  lesions  of  the 
abdominal  or  pelvic  viscera.  In  women  uterine  displacement,  pelvic 
adhesions,  and  organic  tumors  are  not  infrequently  the  cause  especially 
of  vomiting  that  occurs  before  or  during  the  menstrual  period,  although 
menstruation  may  be  regular  and  painless.  In  men  with  enlarged 
prostates  and  retention  of  urine,  nausea  and  vomiting  frequently  occur. 
Rosenberg  and  IlerschelP  alludes  to  these  cases  under  the  name  of 
I'rokinetic  Dyspepsia,  and  consider  them  cxidentlN-  of  toxic  origin. 

'  Dcutsch.  Med.  Woch.,  Augu.st  17,  24,  :U,  1S91);  .Med.  Press  and  Circular,  May 
:{1,  ]'M)r>. 


SEXSORY   NEUROSES  555 

Various  toxemias  are  provocative  of  vomitinj^.  rremic  \'omitinff 
seldom  occurs,  however,  as  an  isolated  single  symptom,  but  is  regularly 
accompanied  by  other  symptoms  and  physical  signs  as  well  as  bj'-  the 
urinary  evidences  of  renal  involvement.  The  vomiting  may  be  accom- 
panied by  pain  or  diarrhea  from  uremic  ulcers  in  the  stomach  or  intes- 
tinal tract.  In  exceptional  cases  the  vomiting  of  uremia  may  be  per- 
sistent at  the  onset,  obscuring  the  other  symptoms  of  the  kidney 
disease. 

Pregnancy  should  always  be  excluded,  especially  difficult  being  the 
early  exclusion  of  extra-uterine  gestation.  The  vomiting  may  be  that 
of  the  ordinary  morning  sickness,  or  may  be  of  a  pernicious  type, 
with  errors  in  the  ammonia  coefficient  and  slight  jaundice  that  indicate 
parenchymatous  degeneration  of  the  liver.  Prolonged  vomiting  may 
be  perpetuated  by  starvation,  acidosis,  and  acetonemia.  In  other  cases, 
nervous  pregnant  women  may  vomit  from  time  to  time  throughout  the 
entire  period  of  gestation  simply  because  the}'  are  nervous,  apprehensive, 
and  afraid  of  what  they  will  inevitably  have  to  pass  through. 

Pulmonary  phthisis  may  be  accompanied  by  vomiting  as  an  initial 
symptom.  The  vomiting  usually  occurs  when  the  patient  rises  in  the 
morning  and  is  preceded  by  tickling  in  the  throat  and  cough.  Retching 
follows  the  eflFort  to  dislodge  sticky  tenacious  mucus,  and  whatever 
there  ma}'  be  in  the  stomach  wdll  come  up.  In  other  cases  every  attempt 
to  partake  of  food  is  followed  by  an  attack  of  coughing  which  terminates 
in  vomiting.  The  emesis  is  not,  however,  preceded  or  accompanied 
by  nausea,  and  usually  shows  no  tendency  toward  spontaneous  recur- 
rence. Similar  morning  emesis  often  accompanies  alcoholism  and  ex- 
cessive smoking.  The  rasping  and  scraping  attempts  to  dislodge  the 
secretions  of  the  smoker's  throat  may  continue  until  emesis  occurs. 

Occasionally  in  tuberculosis  the  vomiting  does  not  depend  upon  the 
irritable  condition  of  the  throat,  but  may  continue  persistently,  often 
for  several  weeks,  the  patient  vomiting  everything  that  is  eaten  during 
that  time.  In  these  cases,  however,  there  is  apt  to  be  considerable 
temperature  and  the  cause  for  the  vomiting  is  often  toxic. 

Vomiting  may  occur  in  heart  disease  during  the  period  of  decom- 
pensation, either  from  congestion  of  the  mucosa  or  from  injudicious 
use  of  drugs,  especially  of  digitalis.  Anorexia  and  epigastric  pain 
from  hepatic  engorgement  complete  the  clinical  picture. 

Malarial  paroxysms  may  be  ushered  in  by  vomiting  and  often  with 
abdominal  pain  suggesting  appendicitis.  According  to  Cabot  three 
such  cases  entered  the  Massachusetts  General  Hospital  in  a  single 
week  and  were  promptly  cured  by  quinine. 

When  the  above  ordinary  causes  for  vomiting  and  others  which  may 
occur  to  the  observer,  but  which  are  not  here  considered,  for  obvious 


550  NEUROSES 

reasons,  have  been  excluded,  there  are  found  to  be  certain  types  of 
cases  which  may  be  inchided  under  the  general  heading  of  nervous 
vomiting,  and  which  divide  themseKes  into  two  groups,  one  accom- 
panying organic  disease  of  the  nervous  system,  the  other  entirely  of 
neurotic  or  psychoneurotic  character. 

Cerebral  vomiting  may  occur  in  many  lesions  of  the  brain  or  membranes 
especially  frequently  with  cerebral  tumor.  The  patient  will  suddenly 
and  without  premeditation  ^•omit  from  time  to  time  without  nausea 
or  other  manifest  distress.  The  vomiting  is  apparently  causeless  and 
propulsive,  and  bears  no  relationship  to  the  quantity  or  the  quality 
of  the  food.  Persistent  and  uncontrollable  vomiting  may  usher  in  an 
attack  of  meningitis,  especially  of  the  tubercular  form,  and  the  vomiting 
may  be  so  persistent  and  violent  as  to  overshadow  the  other  symptoms 
of  meningeal  origin.  Attacks  of  severe  periodical  vomiting  may  occur, 
accompanied  by  severe  headache,  the  ejecta  consisting  of  acid  fluid 
having  all  of  the  characteristics  of  acute  periodical  hypersecretion, 
or  the  gastroxynsis  described  by  Rossbach.  Unless  the  ojjtic  disk  be 
examined,  error  in  diagnosis  may  be  committed. 

Pain  and  vomiting  occur  periodically  in  tabetic  patients  constituting 
the  well-known  gastric  crisis  of  locomotor  ataxia.  (See  Gastric  Crisis, 
p.  591.) 

The  occurrence  of  unexplained  vomiting  with  great  restlessness  and 
incessant  clamoring  for  relief  without  evidences  of  actual  pain  is  rather 
characteristic  of  morphine  habitues  deprived  of  their  drug. 

Occasionally  a  paroxysm  of  vomiting  is  the  sole  manifestation  of  an 
attack  of  nephrolithiasis. 

Vomiting  with  temperature  should  regularly  suggest  the  onset  of  an 
infection,  as  vomiting  in  itself  does  not  produce  fever. 

Hysterical  or  Nervous  Vomiting. — Hysterical  or  nervous  vomiting  of  a 
purely  functional  character  may  })e  seen  in  a  variety  of  types,  and  is 
characterized  in  the  main  by  the  following  peculiarities. 

The  vomiting  act  is  causeless,  unpremeditated,  unaccom])anied  by 
nausea,  and  without  much  muscular  efl'ort.  \'omiting  during  or  shortly 
after  meals  is  suggesti\e  of  the  nervous  origin,  especially  if  the  patient 
return  to  the  table  and  eat  again. 

The  vomiting  shows  no  reasonal)le  (lei)endence  upon  ^\w  character 
of  the  food  that  is  eaten.  Simple  food  may  be  rejected  while  bizarre 
and  unwholesome  selections  of  food  may  be  retained  with  comfort. 
One  j)atient  of  the  writer's  could  for  a  time  eat  nothing  but  chicken 
or  lobster  .salad,  while  another  subsisted  for  se\-eral  days  entirely  on 
popcorn.  Occasionally  freakish  jjatients  are  encountered  who  seem 
to  })ossess  the  art  of  selective  vomiting  and  can  separate  in  some 
mysterious  way  what    they  wish  to  eject    from    the   rest  of   the   meal. 


SEXSORY   NECROSES  '  557 

The  ^•()miting  is  largely  depeiideiit  upon  nervous  conditions  of 
excitement,  fatigue,  emotional  outbursts,  or  apprehension.  Xer\ous 
vomiting  may  occur  in  students  before  their  examinations  or  in  lecturers 
or  actors  before  their  public  appearance.  The  coexistence  or  alterna- 
tion of  other  manifestations  of  a  psychoneurosis  are  often  strikingly 
apparent. 

Despite  even  daily  vomiting,  loss  of  flesh  and  strength  is  quite 
exceptional,  and  there  is  often  a  strikingly  disparity  between  the  healthy 
appearance  of  the  patient  and  the  history  of  her  having  vomited  after 
nearly  every  meal  for  weeks  or  even  months.  Increasing  anemia  and 
loss  of  weight  should  occasion  doubt  as  to  the  purely  neurotic  nature 
of  the  complaint. 

Types. — Three  special  types  of  nervous  vomiting  may  be  described: 

Hysterical  Type. — There  is  a  type  in  which  the  patient  will  go  day 
after  day  vomit'ng  one  or  more  times  a  day,  occasionally  after  every 
meal,  without  nausea  or  distress,  and  without  any  apparent  ill  effects. 
It  would  seem  as  if  the  patient  were  capable  by  some  miraculous  power 
of  existing  indefinitely  without  food.  It  is  probable,  however,  that  only 
portions  of  each  meal  are  rejected,  leaving  sufficient  residue  to  sustain 
a  fair  degree  of  bodily  health.  Psychical  vomiting  may  occur  in  normal 
individuals  whenever  subjected  to  shock,  fright,  or  sudden  mishap.  If 
the  cause  for  such  an  upset  be  repeated,  a  habit  of  vomiting  may  result 
even  in  the  absence  of  a  demonstrable  cause.  Chlorotic  girls  often 
vomit  their  food  without  an}'  apparent  reason  for  so  doing.  When, 
as  is  usual  in  such  cases,  the  menses  are  suspended,  the  diagnosis  from 
early  pregnancy  is  quite  difficult. 

Erb's  Juvenile  Type. — Erb's  juvenile  type  of  vomiting  is  occasionally 
seen  in  susceptible,  high-strung  school  children  who  overstudy  and 
use  up  their  nervous  strength.  The  child  may  simply  vomit  from  time 
to  time  without  apparent  cause,  or  the  symptoms  may  come  in  attacks 
of  headache,  vomiting,  dilated  pupils,  and  occasionally  a  pulse  rate 
somewhat  slower  than  normal.  These  symptoms  cease  during  the  weeks 
of  vacation  or  if  the  child  be  taken  from  school.  It  is  questionable 
whether  Erb's  juA'enile  vomiting  is  a  neurotic  entity  from  overstudy 
or  whether  it  does  not  result  from  some  organic  or  reflex  cause  in  im- 
pressionable overtrained  children  who  are  thus  rendered  unduly  sensa- 
tive  to  such  reflex  stimulations.  Eye-strain  and  masturbation  should 
be  suspected  with  such  a  clinical  history,  and  the  possibility  of  appen- 
dicitis should  also  be  remembered. 

Leyden's  Periodical  Type. — Leyden's  periodical  vomiting  consists  in 
vomiting  attacks  without  apparent  cause  appearing  at  regular  and 
orderly  inter\als.  The  attack  begins  with  epigastric  |)ain  and  \'()miting, 
the  ejecta  consisting  of  what  has  recently  been  eaten,  nnicus  and  iiile. 


558  NEUROSES 

There  may  be  an  abolition  of  hydrochloric  acid  secretion,  although 
gastric  functions  are  usually  normal.  Even  after  the  stomach  has  been 
emptied,  repeated  retching  occurs,  so  that  nothing  is  retained  for  any 
length  of  time.  The  patient  shows  the  effects  of  the  illness  and  becomes 
weak  and  prostrated.  The  attack  may  last  several  hours  or  may  be 
prolonged  for  a  week  or  ten  days.  The  subsidence  of  the  attack  is 
usually  abrupt,  leaving  the  patient  weak  and  exhausted  but  without 
other  definite  complaints.  Recurrences  occur  after  the  lapse  of  several 
weeks  or  months,  the  distinctive  feature  being  the  absolute  regularity 
with  wliicii  the  attack  repeats  itself. 

The  writer  has  not  seen  any  instances  that  seemed  to  belong  to  this 
clinical  type  except  those  with  almost  identical  symptoms  that  were 
evidently  examples  of  the  gastric  crisis  of  tabes. 

Cyclic  Vomiting,  Periodical  Vomiting,  Recurrent  Vomiting. — Cyclic  \om- 
iting  is  a  symptom-complex  occurring  mostly  in  children  and  charac- 
terized by  periodical  attacks  of  vomiting  lasting  from  two  to  ten  days, 
usually  preceded  and  accompanied  by  marked  constipation,  together 
with  acetonuria,  indicanuria,  and  creatinuria. 

Etiology. — The  cause  of  this  condition  is  unknown,  but  it  is  generally 
agreed  that  the  disease  occurs  most  frequently  in  children  having  an 
inherited  or  acquired  neurotic  constitution.  Further,  that  it  is  in  no 
way  connected  with  dietetic  errors. 

Race,  sex,  climate,  or  season  of  the  year  play  no  part  in  its  etiology. 
Family  predisposition  may  be  a  factor,  since  several  cases  have  occurred 
in  the  same  family. 

Theories  as  to  causation  abound.  There  are  those  who  believe  it 
to  be  closely  associated  with  such  other  diseases  as  appendicitis,  ade- 
noids, constipation,  hereditary  gouty  diathesis,  rheumatism,  and 
hepatic  insufficiency.  Others  think  it  to  be  a  pure  neurosis  or  else  con- 
nected in  some  obscure  manner  with  the  erythema  group.  All  of  the 
above  find  their  basis  in  some  clinical  manifestation  of  the  symptom 
complex.  On  the  other  hand  a  number  of  in\estigators  believe  that 
the  disease  has  its  origin  in  a  deranged  metabolism  and  present  more 
or  less  conclusive  proof  for  their  belief.  Experimental  work  has  shown 
the  following  substances  in  abnormal  quantities  in  the  urine  through- 
out the  attack:  acetone,  diacetic  acid,  and  beta-oxybutyric  acid;  uric 
acid,  creatin.  and  neutral  sulphates  are  increased  at  the  beginning  of 
the  attack;  lactic  acid  is  occasionally  found  in  severe  cases;  indican  is 
increased  greatly  before  and  during  the  first  days  of  the  attack. 
According  to  Rowland  and  Richards'  all  of  the  above  may  be  trace- 
able to  a  diminished  ])ower  of  oxidation  of  the  tissue  cells,  hence  they 

'  .\reh.  Pediat..  1907,  |).  401. 


SENSORY  NEUROSES  559 

believe  that  there  is  an  iiiterfereMce  with  certain  metaboHc  processes  in 
which  oxidation  plays  a  part.  They  proved  that  when  the  oxidation 
power  is  diminished,  indol  acts  as  a  poison.  The  accompanying  con- 
stipation furnishes  the  indol  which  thus  acts  as  a  poison  causing  the 
intractable  vomiting. 

Sedgwick^  belie\'es  that  the  metabolic  disorder  expresses  itself  in 
the  constant  presence  of  creatin  in  the  urine,  which  becomes  greatly 
increased  just  prior  to  an  attack  and  gradually  diminishes  between 
attacks  but  never  entirely  disappears. 

Mellamby-  confirms  the  above  findings  and  believes  since  creatin  is 
always  present  that  the  cause  of  the  disordered  metabolism  is  always 
acting  and  that  the  accompanying  acidosis,  while  not  causative,  is 
sufficient  to  produce  the  attack.  He  further  believes  that  the  underlying 
cause  for  the  disordered  metabolism  is  chargeable  to  some  chemical 
product  of  bacterial  action  going  on  either  in  the  intestinal  mucosa  or 
portal  circulation. 

Pathology. — There  have  been  but  few  autopsies  recorded.  The  patho- 
logical findings  consist  of  varying  degrees  of  degeneration  of  the  gastric 
and  intestinal  mucosa.  There  is  fatty  infiltration  of  the  liver,  paren- 
chymentous  degeneration  of  the  pancreas,  spleen,  and  kidneys.  Hyper- 
trophy of  the  pyloric  ring  has  been  noted.  X-ray  plates  taken  near  the 
end  of  attacks  showed  violent  peristaltic  waves  passing  across  the 
gastric  musculature. 

Syviptoms. — The  attacks  may  occur  at  any  time  before  puberty, 
most  often  beginning  in  the  second  or  third  year  of  life  and  continuing 
until  the  tenth  year.  At  first  the  attack  may  take  place  eight  or  ten 
times  a  year  wdth  some  regularity,  but  later  occur  at  longer  intervals  and 
with  less  regularity.  The  attacks  are  ushered  in  with  a  period  lasting 
two  or  three  days  in  which  lassitude,  headache,  abdominal  discomfort 
and  constipation  are  present.  Distaste  for  food,  later  nausea  and  finally 
vomiting  appear,  or  the  vomiting  may  begin  without  any  prodromal 
symptoms. 

Usually  there  is  throughout  the  attack  a  low  grade  of  fever;  generally 
constipation  or  obstipation;  pulse  may  become  very  rapid  and  irregular; 
respirations  may  be  greatly  increased,  irregular,  and  sighing.  The  odor 
of  acetone  usually  permeates  the  sick  room.  Pain  is  frequently  com- 
plained of  but  not  definitely  localized.  Patients  are  at  first  very  restless 
but  later  become  exhausted  and  lie  curled  up  in  bed.  There  is  inten.se 
thirst,  the  eyes  become  sunken,  the  body  rapidly  emaciates.  The 
mind  usually  remains  clear,  but  if  the  acidosis  is  extreme  there  may 
be  marked  stupor. 

'  Amer.  .Jour.  Dis.  Child.,  1912,  p.  209.  =  Lancet,  July  1,  1911,  p.  8. 


560  NEUROSES 

In  mild  cases  the  vomiting  occurs  spontaneously  with  but  little 
retching.  First  the  stomach  contents  are  expelled,  then  the  gastric 
juice  and  later  the  vomitus  is  composed  of  a  bile-stained  fluid.  The 
vomiting  may  continue  for  two  or  three  days  and  the  attack  then  cease. 
The  patient  will  then  be  perfectly  well  until  another  attack.  In  more 
severe  cases  the  vomiting  may  occur  every  few  minutes,  accompanied 
by  marked  retching.  If  food  be  taken  it  is  immediately  expelled. 
The  patient  is  unable  to  retain  water.  Owing  to  lack  of  nutrition  and 
lack  of  water  there  is  rapid  decrease  in  weight.  The  muscles  used  in 
emesis  become  tender,  the  throat  is  inflamed,  and  the  abdomen  sunken. 
This  may  continue  fi^•e  or  six  days  and  the  case  assume  a  very  serious 
aspect,  when  suddenly  the  vomiting  ceases,  the  patient  takes  food  and 
water,  and  convalescence  proceeds  rapidly.  In  the  very  severe  cases 
the  vomiting  and  retching  completely  exhaust  the  patient,  the  vomitus 
becoming  at  times  streaked  with  blood  or  even  distinctly  bloody. 
There  is  marked  emaciation,  deeply  sunken  eyes,  and  frequently  the 
patient  enters  into  a  state  of  semi-stupor,  from  which  after  protracted 
convalescence  recovery  may  occur,  or  the  case  may  go  on  to  fatal 
termination.  In  these  very  few  severe  cases  the  child  gradually  sinks 
into  coma  and  dies  of  the  symptoms  of  acid  intoxication  in  spite  of  all 
measures  to  counteract  it.  In  others  the  fatal  termination  may  be 
brought  on  by  inanition  and  loss  of  water,  together  with  the  exhaustion 
due  to  the  constant  vomiting.  Very  few  cases,  however,  result  fatally. 
Nearly  all  convalesce  rapidly,  and,  as  a  rule,  are  perfectly  well  until 
some  exciting  cause,  such  as  fright,  worry,  fatigue,  a  railway  journey, 
or  some  happening  out  of  the  ordinary  brings  on  another  attack.  These 
gradually  increase  in  severity  up  to  the  fifth  year,  when  their  intensity 
is  diminished  and  finally  about  puberty  disappear  entirely,  or  they  may 
continue  in  adult  life  as  attacks  of  migraine. 

Diagnosis. — This  condition  must  be  dift'erentiated  from  indigestion, 
acute  poisoning,  migraine,  meningitis,  intestinal  obstruction,  peri- 
tonitis, and  appendicitis.  A  history  of  previous  attacks,  together  with 
the  finding  of  acetone  bodies  in  the  urine,  is  of  great  importance  in 
arri\ing  at  an  early  diagnosis.  In  the  absence  of  history,  together  with 
the  lack  of  signs  of  acute  inflammation,  one  can  temporarily  rest  a  diag- 
nosis on  the  finding  of  the  acetone  })odi(>s.  The  diagnosis  is  confirmed 
when  the  attack  ends  suddenly  and  the  acetone  bodies  disappear  from 
the  urine. 

Prognosis. — A  favorable  i)r()gn()sis  may  be  made  first  as  to  recovery 
and  secondI\'  for  complete  cessation  of  attacks.  Ik)th  parents  and 
physician  Ix-conie  more  or  less  assured  after  having  brought  the 
l)ati('nt  through  several  similar  attacks,  and  soon  a  prescribed  routine 
is  followed   with  fa\'orable  results. 


MOTOR  NEUROSES  561 

Treatment. — In  the  matter  of  treatment,  not  knowing  the  cause, 
we  have  no  specific  cure.  As  a  rule  attacks  come  and  go  unin- 
fluenced by  medication.  Prophyhictic  measures,  such  as  removal  of 
adenoids,  tonsils,  and  appendix,  circumcision,  prevention  of  consti- 
pation, and  measures  to  overcome  neurotic  tendencies,  all  have 
their  advocates.  Considering  the  attack  as  due  to  a  deranged 
metabolism  in  which  acid  products  are  unneutralized,  rational  thera- 
peusis  would  indicate  an  active  alkaline  treatment.  Considering  indol, 
skatol,  and  phenol  as  intestinal  products  whose  toxicity  is  greatly 
increased,  indications  for  their  removal  are  apparent,  hence  a  calomel 
purge  followed  later  by  high  colon  irrigations  is  often  advisable.  It 
is  essential  that  the  bowels  be  kept  open  freely  throughout  the  attack. 
The  marked  loss  of  water  from  the  system  must  be  compensated  for 
by  water  per  mouth  if  possible;  if  not,  by  saline  per  rectum  or  subcu- 
taneously.  Lavage  and  gavage  may  be  tried  but  are  usually  useless. 
Patients  seldom  can  retain  food  in  stomach,  hence  nutrient  enemas 
rich  in  carbohydrates  must  be  given.  When  vomiting  threatens  exhaus- 
tion, relief  must  be  given  by  morphine.  The  usual  antimetics  have 
no  effect.  To  break  the  habit  is  the  main  thing  no  matter  what  means 
are  used.  Cabot  mentions  an  apparently  sensitive  workingman  of 
thirty-fi\'e,  who  ^'omited  continuously  from  habit  until  he  had  lost  55 
pounds  in  weight,  and  was  finally  cured  after  a  four  months'  duration 
of  his  vomiting  by  subpectoral  infusions  of  saline  solution. 


MOTOR   NEUROSES 

Perigastric  Unrest. — This  term  was  used  by  Kussmaul  to  describe 
a  peristalsis  of  the  stomach,  more  or  less  continuously  visible,  not 
dependent  upon  pyloric  obstruction.  It  is  doubtful  if  it  exists  as  a 
clinical  entity  of  a  pure  neurosis. 

Rumination. — Rumination  consists  in  voluntarily  bringing  up  food 
in  small  portions  so  that  it  may  be  either  ejected  or  remasticated  and 
again  swallowed.  If  rumination  occurs  soon  after  meals  the  regurgitated 
portions  of  food  may  retain  their  original  taste,  but  rumination  later 
in  the  process  of  digestion  brings  up  food  either  sour  or  bitter.  Rumina- 
tion is  more  common  in  men  than  in  women,  occurring  only  in  10  women 
of  145  instances  reported  by  Presslich.^  According  to  Eisner  the  habit 
is  common  in  achylia  and  h^'persecretion,  but  this  cannot  be  verified 
by  the  writer. 

The  mechanism  of  rumination  is  imperfectly  understood.  It  has  been 
supposed  that  the  habit  depends  upon  relaxation  of  the  cardia,  but 

1  Wien.'med.  Woch.,  1904,  17  tol21. 
36 


562  NEUROSES 

against  this  theory  are  the  facts  that  the  reswallowed  food  is  retained 
without  being  again  regurgitated  and  when  the  stomach  is  artificially 
inflated  the  air  does  not  escape.  The  habit  has  been  thought  by  some 
to  be  due  to  dilatation  of  the  lower  end  of  the  esophagus  and  by  others 
considered  the  result  of  irritation  of  the  vagus,  producing  an  opening 
of  the  cardia  and  antiperistalsis  of  the  esophagus. 

It  has  been  thought  that  heredity  plays  a  part  in  predisposing  to 
the  ailment,  as  in  a  number  of  instances  several  members  of  a  family 
have  been  alike  affected.  It  is  more  probable,  however,  that  the  habit 
is  acquired  by  imitation,  as  an  instance  has  been  reported,  for  example, 
of  a  ruminating  governess  who  was  imitated  by  two  of  her  pupils.  The 
writer  is  more  inclined  to  regard  rumination  as  a  faulty  habit.  The 
most  marked  example  which  he  has  ever  seen  occurred  in  a  young  man 
who  was  imprisoned  in  Russia  for  a  political  offence,  and  who  contracted 
the  habit  because  his  food  was  so  scanty  that  it  was  only  by  rumination 
that  he  could  sufficiently  protract  his  meal.  This  individual  had  the 
power  of  selection,  so  that  after  a  mixed  meal  he  could  separate  any  one 
article  of  food  and  bring  it  up  for  remastication. 

The  treatment  of  rumination  is  that  of  an  evil  habit,  by  autosup- 
pression  and  psychotherapy.  The  patient  should  be  forced  to  eat 
slowly  and  to  masticate  thoroughly.  Strychnine  and  quinine  are  of 
service  only  because  of  their  bitter  taste.  They  remind  the  patient 
that  he  is  ruminating.  Intragastric  galvanism  with  the  descending 
current  has  been  employed  with  striking  results,  probably  the  result 
of  therapeutic  suggestion. 

Hypermotility. — Hypermotility  is  a  term  designating  an  acceleration 
of  food  exit  from  the  stomach  so  that  the  organ  is  empty  before  the 
normal  time.  The  condition  may  occur  occasionally  as  a  temporary 
motor  neurosis  but  is  not  of  any  clinical  importance.  Hypermotility 
is  said  to  be  common  with  achylia.  This  is  true  in  the  writer's  experi- 
ence in  a  few  but  not  in  the  majority  of  instances.  Rapid  evacuation 
of  the  stomach  in  the  absence  of  the  acid  reaction  required  to  open  the 
pyloric  gate  is  a  problem  not  easily  explained.  It  is  claimed  that 
hypermotility  is  common  with  duodenal  ulcer,  as  fluoroscopy  shows 
rapid  entrance  of  the  bismuth  meal  into  the  duodenum. 

Pyloric  Insufficiency.  This  may  ensue  from  organic  lesions  of  the 
pylorus,  such  as  cicatrizing  ulcer  or  cancer,  which  produces  a  rigid 
patency  of  the  orifice,  which  acts  in  two  ways.  The  opening  is  not 
sufficient  for  the  easy  passage  of  food  from  the  stomach  to  the  duodenum 
and  at  the  same  time  cannot  contract  sufficiently  to  prevent  duodenal 
regurgitation.  The  condition  may  be  recognized  by  finding  food 
remains  in  the  fasting  state,  together  with  bile  and  other  contents  of 
the  small  intestines. 


SECRETORY  NEUROSES  563 

Pyloric  insufficiency  from  neurotic  causes  is  extremely  rare.  The 
condition  may  be  surmised  whenever  air  introduced  into  the  stomach 
for  the  purpose  of  inflation  passes  into  the  intestine  simultaneously 
with  a  rapid  deflation  of  the  stomach  itself,  or  when  in  apparently 
normal  individuals  bile  and  pancreatic  juice  are  repeatedly  present 
in  the  fasting  stomach.  After  the  patient  is  thoroughly  accustomed 
to  the  passage  of  the  tube,  the  condition  is  difficult  to  be  distinguished 
from  the  duodenal  regurgitation  following  an  excessively  fatty  diet, 
and  may  occasionally  be  indistinguishable  from  the  duodenal  distention 
that  results  from  duodenojejunal  kinks. 


SECRETORY   NEUROSES 

Disorders  of  secretion,  either  consisting  of  subacidity  or  hyper- 
acidity, may  be  of  nervous  or  functional  origin.  Hyperacidity  was  ap- 
parently a  nervous  phenomenon  in  20  per  cent,  of  the  Avriter's"  series, 
or  to  state  it  more  accurately,  in  20  per  cent,  of  the  writer's  cases  of 
hyperacidity  no  organic  cause  could  be  ascertained.  This  does  not 
necessarily  imply,  however,  that  organic  disease  did  not  exist.  In 
functional  hyperacidity  neither  heart-burn  nor  pain  seem  to  occur, 
nor  was  vomiting  a  feature  of  the  ailment,  so  that  the  presence  of  any 
one  of  these  symptoms  would  suggest  organic  origin  for  the  hyper- 
chlorhydria.  The  subject  is  discussed  in  full  under  Hyperacidity, 
page  463. 

Achylia  may  undoubtedly  be  due  to  a  nervous  inhibition  of  secretion. 
It  is  a  matter  of  common  experience  that  a  meal  eaten  under  great 
nervous  excitement  or  fatigue  may  be  vomited  within  a  few  hours 
completely  undigested  and  show  no  trace  of  gastric  juice. 

Temporary  achylia  may  also  precede  menstruation  or  may  be  noted 
during  the  first  day  or  two  of  the  period.  These  instances  of  nervous 
achylia  are  of  short  duration,  the  flow  of  gastric  juice  being  normally 
established  whenever  the  nervous  system  becomes  again  tranquillized. 

In  other  instances  achylia  may  appear  as  a  permanent  condition 
without  apparent  cause  in  those  who  are  otherwise  healthy  in  every 
particular.  One-third  of  the  writer's  cases  of  achylia  occurred  in  those 
in  whom  a  physical  examination  was  absolutely  negative.  It  is  inter- 
esting to  note,  however,  that  with  gastroptosis  a  condition  almost 
invariably  accompanied  by  neurasthenia  more  or  less  profound,  achylia 
has  not  occurred  in  the  writer's  series  more  frequently  than  in  a  similar 
number  of  patients  not  so  afflicted. 

(lastric  symptoms  with  achylia  should  suggest  lesion  in  the  gall- 
bladder or  appendix   or   the   possibility  of   an   arteriosclerotic  origin. 


564  NEUROSES 

Achylia  with  food-stasis  should  suggest  cancer.  A  discussion  on  the 
various  aspects  and  causes  of  achyha  is  given  on  page  482. 

Instabihty  of  gastric  secretion  is  observed  in  some  neurotic  patients 
and  is  demonstrated  by  fluctuations  of  acidity  without  apparent 
reason  in  the  same  individuaL  An  example  of  this  so-called  "hetero- 
chylia"  is  that  of  a  patient  of  the  writer's,  a  nervous  woman,  profoundly 
depressed  by  domestic  infelicity,  in  whom  the  test  breakfast  on  one 
day  was  of  a  total  acidity  of  7S,  the  following  morning  of  G.  In  another 
patient  suffering  from  petit  mal,  achylia  was  present  one  da}',  while 
on  the  following  morning  the  test  breakfast  showed  an  acidity  of  136. 
Heterochylia  affords  corroborative  evidence  of  a  neurosis,  but  as  it 
may  coexist  with  organic  disease  it  is  of  less  value  in  diagnosis  than 
one  would  imagine.  The  greatest  lessori  to  be  learned  from  the  symytom 
is  that  more  than  one  gastric  analysis  is  necessary  for  the  com'plete  study 
of  a  given  case. 

Continuous  hypersecretion  indicates  a  rudimentary  form  of  pjdoric 
stenosis,  either  spasmodic  or  organic,  and  cannot  therefore  be  regarded 
as  evidence  of  a  neurosis.  Alimentary  hypersecretion,  according  to 
the  German  school,  occurs  in  nervous  individuals  who  present  the 
symptoms  of  nervous  indigestion.  This  is,  however,  contrary  to  the 
writer's  experience. 

TREATMENT    OF    GASTRIC    NEUROSES 

Tact,  consideration,  and  real,  not  maudlin,  sympathy  are  required. 
A  mental  attitude  of  boredom  when  called  on  to  treat  nervous,  whimsical, 
and  hypochondriacal  patients  is  fatal  to  good  results.  Failure  to  relieve 
our  patients  is  often  due  to  the  negligent  and  casual  way  with  which 
we  treat  them,  and  to  our  utter  lack  of  human  sympathy.  Their 
complaints  may  not  be  very  interesting  oftentimes  to  us,  but  to  them 
they  are  real,  vivid,  and  harassing,  and  their  mental  distress  may  be 
as  devitalizing  as  actual  physical  pain.  Nervous  indigestion  is  after 
all  a  habit  neurosis  in  many  instances,  and  the  only  way  to  permanently 
check  the  habit  is  by  reeducation  of  the  nervous  centres. 

The  treatment  is  that  practically  of  suggestion,  of  quieting  undue 
fears  and  apprehensions,  arousing  ambitions  and  self-hclj),  and  inspiring 
the  patient  with  a  sense  of  his  own  power  of  helping  himself. 

We  may  or  may  not  be  able  to  change  environment.  Time  brings 
heaMng  on  its  wings  after  n^'rvous  shocks  and  \icissitudes  of  fate, 
but  tiic  difficult  ])r()bl('ni  is  to  deal  successfully  with  those  that  are 
tenijx'ranu'utally  unfitted  for  the  ])lace  in  life  in  which  they  have  to 
remain.  Especially  is  this  the  case  with  those  afflicted  with  the 
enteroptotic  habitus  who  are  small  capitalists,  easily  bankrui)t  in 
every  nerxous  i^anic. 


TREATMENT  OF  dAHTRIC  NE(' ROSES  565 

[{est,  travel,  and  freedom  from  care  and  worry  are  all  desirable  and 
may  be  carried  out  with  more  or  less  completeness,  according  to  the 
circumstances  of  the  given  case.  Daily  routine  occupation  often  takes 
patients  out  of  themselves,  so  that  many  are  better  for  hard  and 
engrossing  work.  There  should  in  all  cases  be  a  proper  equilibrium 
between  nervous  outgo  and  nervous  income.  Work  and  activity  should 
be  balanced  by  corresponding  periods  of  rest  and  recreation.  In  many 
instances  absolute  rest  for  a  certain  period  in  the  afternoon  should  be 
encouraged.  In  those  who  are  debilitated,  especially  those  with  visceral 
ptoses,  a  rest  cure  is  often  essential  for  their  restoration  to  health. 

It  is  of  importance  to  see  that  the  patients  eat  enough.  Their  natural 
tendency  is  to  be  unduly  apprehensive  and  to  attribute  their  distress 
to  the  food  that  they  have  recently  eaten,  so  they  cut  down  their  diet 
and  restrict  themselves. 

The  treatment  is  essentially  irrational  when  the  victim  of  nervous 
indigestion  is  allowed  continually  to  lose  weight.  Another  natural 
tendency  is  for  the  patients  to  overmedicate  themselves  and  to  be 
constantly  taking  headache  powders,  despepsia  tablets,  and  any  remedy 
that  may  be  suggested  by  s^'mpathetic  but  not  always  intelligent 
friends.  Bromides  may  be  of  service  for  short  periods  of  time  to  tide 
over  exacerbations  of  the  ailment,  but  this  treatment  should  not  be 
long  continued  for  reasons  that  are  quite  obvious. 

Treatment  of  Special  Symptoms, — Anorexia. — A  change  of  scene  is 
often  desirable,  especially  for  nervous  housekeepers  who  have  to  plan 
ahead  for  their  meals.  Food  taken  in  solitude  is  unappetizing  compared 
with  that  enlivened  by  pleasant  associates. 

Drugs  are  of  little  service.  Menthol  may  be  given  in  half-grain 
doses,  either  in  capsules  or  in  the  following  prescription  before  meals: 

I^ — Menthol gr.  xvi 

Alcohol 5ss 

Syrup.  simpUcis ad  §iv 

M .     Sig. — Teaspoonf 111  in  water  before  meals. 

Orexin  tannate  in  5-grain  doses  has  been  recommended,  but  in  the 
writer's  experience  has  been  practically  worthless.  A  common  form 
of  treatment  is  that  of  bitters  with  or  without  nux  vomica,  and  is 
perhaps  the  most  reliable  of  all  medicinal  treatments. 

The  following  prescriptions  may  prove  of  service: 

F^ — Tinct.  nucis  vomicae 5v 

Ehxir  condurango ad     5iv 

M.    Sig. — Teaspoonf ul  in  water  before  eating. 

I^ — Tinct.  physostigma 3iv 

Tinct.  chamomilla  comp ad     5iv 

M.    Sig.— Teaspoonful  in  water  before  meals. 


566  NEUROSES 

Achylia. — If  achylia  be  present,  dilute  hydrochloric  acid  or  oxyntin 
may  be  given  during  or  after  the  meals.  It  is  important  to  see  that 
the  patient  does  not  drink  too  much  water  between  his  meals  so  that 
he  is  producing  an  artificial  plethora  which  effectually  reduces  his 
desire   for   food. 

Bulimia. — Bulimia  is  to  be  combated  by  mental  suggestion.  Drugs 
are  of  no  avail  in  this  condition.  The  patient  may  be  advised,  however, 
to  carry  chocolate  tablets  in  his  pocket  so  as  to  relieve  the  craving  for 
food. 

Hyperesthesia. — Hyperesthesia  is  to  be  treated  by  attention  toward 
the  underlying  condition.  In  gouty  subjects  the  treatment  should  be 
directed  toward  this  diathesis.  An  experimental  treatment  by  col- 
chicum  is  often  of  service  in  establishing  the  diagnosis.  When 
hyperesthesia  is  a  reflex  manifestation  of  gallstones  or  of  gall-bladder 
infection,  treatment  toward  the  latter  condition  is  indicated.  A  course 
of  Carlsbad  water,  either  the  imported  or  the  artificial,  should  be  given 
as  hot  as  can  be  sipped  the  first  thing  in  the  morning,  and  one-half 
such  a  dose  on  retiring,  limiting  the  quantity,  however,  so  that  not  more 
than  the  liquid  or  two  uniform  bowel  evacuations  will  result.  Ten 
grains  of  sodium  salicylate  in  hot  water  may  be  given  before  breakfast 
and  before  dinner,  or  2  tablets,  7^  grains  each,  of  sulpholythin  with 
hexamethylenamine  (Laine  Chemical  Co.)  may  be  given  with  a  glass 
of  hot  water  a  half-hour  before  each  meal. 

Gastralgia. — The  principles  of  treatment  are  quite  evident  from  the 
consideration  of  what  has  been  said  concerning  this  symptom.  Chlorotic 
girls  should  be  treated  by  iron  and  saline  laxatives.  Syphilitic  patients 
should  receive  appropriate  treatment.  The  possibility  of  malarial  infec- 
tion must  be  borne  in  mind.  As  gastralgia  is  of  rare  occurrence  as  a 
pure  neurosis  the  treatment  of  pain  in  the  stomach  is  naturally  that 
of  the  underlying  organic  disorder  to  which  the  pain  is  due. 

Vomiting. — The  treatment  of  nervous  vomiting  is  a  thankless  task, 
although  more  results  are  to  be  expected  from  general  treatment  than 
from  medication  of  a  more  purely  local  character.  A  variety  of  anti- 
emetics may  be  used,  such  as  resorcin,  menthol,  drop  doses  of  carbolic 
acid,  or  of  diluted  hydrocyanic  acid,  but  the  effect  produced  is  temporary 
and  the  disorder  speedily  recurs.  The  treatment  is  generally  unsatis- 
factory unless  a  definite  cause  for  the  vomiting  can  be  discovered. 

Nervous  Eructations. — The  treatment  concerns  itself  largely  with  the 
correction  of  the  underlying  neurosis  and  is  usually  a  thankless  task. 
Instances  have  been  reported  of  rapid  and  complete  cure  after  the  nature 
of  the  ailment  has  l)een  explained  to  the  patient,  but  in  the  writer's 
experience  explanations  as  lucid  and  convincing  as  lay  in  his  power 
have  not  influenced  in  the  least  the  severity  of  the  c()mi)laint. 


TREATMENT  OF  GASTRIC  NECROSES  567 

Psychotherapy  and  aiit()su^ji:esti()ii  sliould,  however,  constitute  an 
important  part  of  the  treatment.  Mitigati(jn  of  the  (hstress  by  drugs 
is  often  a  thankless  task.  Bromides,  valerian,  and  chloroform  water 
may  be  employed — belladonna  may  be  given  to  the  point  of  mild 
physiological  intolerance,  and  while  the  results  may  for  a  time  be 
apparently  encouraging,  and  results  are  usually  quite  disappointing, 
while  in  many  cases  not  the  least  effect  can  be  apparently  produced. 

Should  the  eructations  recur  so  rapidly  that  the  patient  is  becoming 
worn-out,  temporary  relief  follows  the  placing  of  a  cork  between  the 
teeth,  thereby  impeding  or  preventing  the  pharyngeal  spasm.  A  similar 
effect  is  produced  by  passing  a  stomach-tube  and  retaining  it  in 
position  for  a  quarter  to  a  half-hour  at  a  time,  with  the  additional 
advantage  of  wearing  out  the  spasm. 


CHAPTER  XXI 
VARIOUS  DISEASES  AND  THEIR  GASTRIC  RELATIONS 

APPENDICITIS 

Forms. — Appendicitis,  both  acute  and  chronic,  is  a  frequent  cause 
for  upper  abdominal  pain. 

Acute  Appendicitis. — Acute  appendicitis  often  begins  by  severe  epi- 
gastric pain  and  vomiting.  The  diagnosis  often  made  of  acute  gastritis 
is  always  unjustifiable  when  pain  is  present.  Acute  painful  "gastritis" 
should  suggest  ulcer,  acute  appendicitis,  or  acute  hypersecretion.  The 
latter  condition  can  be  readily  excluded  if  the  vomited  matters  do  not 
consist  of  acid  liquid.  A  downward  radiation  of  the  pain  is  suggestive 
of  acute  appendicitis,  as  such  a  distribution  is  not  observed  with  ulcer. 
The  pain  gradually  moves  downward  to  the  middle  abdominal  zone 
and  finally  centres  in  the  right  iliac  fossa,  making  certain  the  diagnosis. 

A  polynucleosis  may  be  of  service  in  the  diagnosis  if  present  during 
the  early  stage  of  the  complaint. 

Chronic  Appendicitis. — Chronic  appendicitis  is  responsible  for  many 
errors  in  diagnosis,  as  the  disease  is  capable  of  generating  a  great  ^•ariety 
of  gastric  complaints  without  revealing  itself  either  by  the  history  of 
previous  attacks  of  inflammation  or  by  pain  or  tenderness  in  the  right 
iliac  fossa,  even  though  repeated  careful  examinations  be  made.  The 
diagnosis,  therefore,  in  many  cases  is  arrived  at  by  a  process  of  exclusion 
and  the  appendix  removed  on  the  supposition  that  it  is  the  fons  et 
origo  iiiali  without  being  clinically  convicted  of  guilt.. 

Symptoms. — The  writer  does  not  intend  to  describe  the  symptoms 
of  chronic  appendicitis  in  full  detail,  but  merely  to  speak  of  the  gastric 
symptoms  which  such  a  condition  may  produce  and  which  may  be 
confused  with  local  disorders  of  the  stomach.  The  gastric  symptoms 
of  chronic  appendicitis  may  be  divided  into  four  clinical  groups. 

I.  Pain  Type. — Bilious  attacks  in  children  with  pain,  headache,  and 
vomiting,  usually  ascribed  to  an  unwholesome  meal,  frequently  cul- 
minate in  an  obvious  attack  of  appendicitis.  After  operation  the  bilious 
attacks  cease.  In  those  on  whom  no  operation  is  performed  the  symp- 
toms of  these  early  attacks  may  continue  through  childhood  and  grad- 
ually merge  into  those  that  closely  resemble  gastric  ulcer.  Pain  maj' 
occur  two  or  three  hours  after  eating  and  be  relieved  by  eating,  as  in 


APPENDICITIS 


569 


ulcer.     The  cause  for  sucli  rofurriiifi;  distress  is  a  protect i\e  spasm  of 
the  pyloric  sphincter,  wliich  is  of  itself  sufficient  cause  for  pain.     A 


Fig.   li; 


Pain  line  in  a  case  of  chronic  appendicitis,  with  hunger  pain  relieved  by  eating.     Cured  by 
appendectomy.      (Circles  represent  meals.) 

mild  form  of  chronic  hypersecretion  almost  regularly  accompanies  the 
paroxysm  and  is  an  added  factor  in  increasing  the  severity  of  the 
distress. 

Fig.   118 


Pain  curve  of  a  case  of  uncomplicated  chronic  appendicitis  cured  by  operation.  The  pain  line 
conforms  to  that  of  the  hunger  pain.  The  arrows  indicate  eructations  of  gas  which  are  followed  by 
temporary  relief. 


In  some  instances  the  feeling  is  one  of  great  distress  temporarily 
relieved  by  raising  gas — more  completely  relieved  by  eating. 

Pain  in  the  stomach  occurs  after  eating,  as  in  ulcer,  but  the  time  of 
its  appearance  after  the  meal  is  less  definite  than  in  the  latter  disease 


570      VARIOl'S   DISEASES   AXD   THEIR  GASTRIC  RELATIONS 

and  lacks  its  clock-like  regularity.  The  pain  may  thus  appear  on  one 
day  an  hour  after  meals  and  on  other  days  two  or  three  hours  after 
food  has  been  taken.  Its  capricious  appearance  is  recognized  by  the 
patients,  who  often  say  their  pain  comes  at  any  time.  This  irregularity 
of  the  pain  after  the  meals  is  of  value  in  differential  diagnosis,  but 
unfortunately  in  many  instances  the  pain  appears  with  the  same  definite 
regularity  after  eating  as  does  the  i)ain  of  ulcer,  so  that  a  differential 
diagnosis  may  be  utterly  impossible. 


'II'' 

,  I  I  I  I  I  I 


<r>-L^^5>^<£) 


L%i4>^^V-^^^l^^^ 


X  VOMITED  DINNER  WITHOUT  RELIEF 


Pain  curve  of  an  uncomplicated  case  of  chronic  appendicitis  cured  by  operation.  The  pain  during 
the  day  is  of  the  hunger  type,  relieved  by  eating.  (The  smaller  circles  indicate  nourishment  given 
between  the  regular  meals.)  The  evening  pain  is  unrelieved  by  eating  or  vomiting,  ceasing  only  by 
rest.     This  evening  type  of  pain  is  not  uncommon  with  appendicitis,  rare  with  ulcer. 


It  is  suggesti\e  of  appendicular  gastralgia  when  exertion  or  hard 
physical  work  increases  the  severity  of  a  pain  which  food  has  caused. 
It  is  also  suggestive  of  the  appendicular  origin  of  the  pain  that  relief 
aff(jrde(l  by  food,  drink,  or  alkalies  is  less  immediate  and  complete  than 
in  ulcer.  In  some  instances  the  pain  has  no  definite  relationship  what- 
ever to  the  taking  of  food,  but  is  more  or  less  continuous,  lasting  for 
two  or  three  days  without  intermission,  although  at  no  time  very 
severe,  and  then  ceasing  until  it  recurs  with  a  succeeding  attack. 

The  location  of  the  pain  roughly  speaking  is  ej)igastric,  but  lacks 
the  accurate  localization  that  is  seen  in  ulcer.  In  many  cases  the  pain 
is  felt  lower  down  in  the  abdomen  below  or  to  the  right  of  the  navel, 
and  even  though  the  pain  may  originate  in  the  epigastrium  radiation 
downward  toward  the  umbilicus  or  lower  alxlomen  may  occur.  This 
r;i(iiati(»ii  seldom,  if  c\(t,  occurs  with  ulcer  or  disease  of  the  gall-bladder. 


APPENDICITIS  .)<  I 

One  of  the  most  practical  rules  in  distiiifjuishinfi;  between  ulcer  and 
the  appendicular  form  of  indigestion  is  afi'orded  by  the  behavior  of  the 
{)atient  with  sup[)osed  ulcer  during  his  ulcer  cure.  If  after  two  weeks 
of  treatment  the  original  symptoms  persist,  even  though  they  be  in  a 
modified  and  less  severe  form,  chronic  appendicitis  must  be  considered 
possible.  In  many  cases,  however,  a  ditt'erential  diagnosis  cannot  be 
made — only  operation  can  decide. 

Fig.    121 


Pain  chart  of  a  case  of  acute  exacerbation  of  chronic  appendicitis.  The  pain  on  the  first  day  is  prac- 
tically continuous  and  unrelieved  by  eating.  The  pain  on  the  second  day  is  practically  unchanged  by 
eating  dinner.     The  morning  pain  on  the  third  day  is  that  of  the  hunger  tj'pe. 


The  following  history  shows  how  closely  the  clinical  course  of 
appendicitis  approaches  that  of  ulcer. 

Illustrative  Case. — G.  S.  M.,  male,  aged  thirty-four  years, 
entered  the  hospital  with  the  following  history:  He  had  always  been 
free  from  indigestion  and  from  all  abdominal  distress  until  a  year  ago, 
when  he  began  to  suffer  from  pain  in  the  pit  of  the  stomach  between 
two  and  three  hours  after  eating,  lasting  until  he  ate  again.  Instant 
relief  followed  the  ingestion  of  food,  and  the  larger  the  meal  the  longer 
the  period  of  comfort  that  succeeded.  These  symptoms  have  persisted 
with  great  regularity  since  the  onset,  so  that  he  has  not  been  free  from 
pain  for  a  single  day.  Spontaneous  vomiting  has  not  occurred,  but 
he  has  often  induced  emesis  to  relie\'e  himself  of  pain,  and  almost 
invariably  with  success. 

Physical  examination:  Stomach  is  apparently  of  normal  shape  and 
size.  There  is  a  markedly  tender  point  localized  just  over  the  ensiform. 
Head's   hyperesthetic  zone  is  well-marked,  terminating  behind    in    a 


572      VARIOUS  DISEASES  AND  THEIR  GASTRIC  RELATIONS 

distinct  dorsal  point  of  tenderness.  Repeated  examinations  showed  no 
tenderness  in  the  riglit  iliac  fossa.  Fasting  stomach  contained  25  c.c.  of 
clear  fluid  without  food  remains.  Total  acidity  00,  free  hydrochloric 
acid  45.  Test  breakfast:  160  c.c.  well-digested  breadstuff',  separating 
on  standing  into  two  layers,  the  supernatant  layer  being  two  and  a 
half  times  the  depth  of  the  sedimentary  layer.  Total  acidity  98,  free 
hydrochloric  acid  60,  slight  trace  of  occult  blood  present. 

Patient  was  placed  upon  the  von  Leube  ulcer  cure  for  four  weeks. 
The  symptoms  improved  markedly  after  the  fourth  day,  but  did  not 
entirely  disappear,  and  at  times  he  would  sufler  from  a  mild  discomfort 
two  or  three  hours  after  eating.  This  discomfort  was,  however,  so 
insignificant  that  he  regarded  himself  as  cured.  The  tenderness  in  the 
epigastrium  completely  disappeared.  After  he  had  been  up  and  around 
the  ward  for  several  weeks  he  suddenly  complained  of  intense,  agonizing 
pain  in  the  epigastrium,  radiating  thence  over  the  whole  of  the  abdomen, 
and  passed  into  a  condition  of  surgical  shock.  The  abdominal  wall  was 
rigid  and  board-like,  his  temperature  subnormal,  his  pulse  rapid  and 
feeble.  Exploration  for  a  supposed  perforation  of  a  duodenal  ulcer 
was  done  two  hours  after  onset  of  pain.  The  stomach  was  normal, 
inside  and  outside,  as  was  the  duodenum.  A  perforation  of  the  appendix 
had  occurred  from  acute  gangrene  of  its  tip  without  adhesions.  Re- 
covery from  the  operation  was  uneventful,  and  for  the  following  two 
years,  during  wdiich  time  the  patient  was  under  observation,  he  had 
no  gastric  distress  of  any  kind,  but  could  eat  all  sorts  of  food  with 
impunity. 

II.  Nausea  Type. — A  persistent  nagging  nausea  may  be  the  sole 
symptom  of  appendicular  disease.  The  nausea  is  seldom  pronounced, 
but  is  of  low-grade  intensity,  characterized  by  its  constancy  rather 
tlian  its  severity.  It  comes  and  goes  throughout  the  day,  sometimes 
before  meals  and  other  times  after  meals,  and  having  no  fixed  time 
for  its  appearance.  It  does  not  seem  to  interfere  with  a  reasonable 
enjoyment  of  food,  nor  is  it  made  worse  by  eating.  Such  a  history  is 
as  follows: 

Mrs.  L.,  aged  forty-three  years,  for  six  or  seven  years  has  been  nau- 
seated every  day,  although  seldom  to  the  ])oint  of  \'omiting.  Despite 
the  nausea  she  has  been  able  to  eat  and  to  digest  her  food  with  comfort. 
All  forms  of  treatment,  including  anchoring  the  kidney,  have  produced 
no  beneficial  result  whatever.  For  the  past  two  months  she  has  com- 
plained of  an  occasional  pain  in  the  stomach,  not  due  to  gas,  appearing 
about  two  hours  after  eating  and  lasting  until  she  has  eaten  again. 
One  week  ago  the  definite  symptom  of  an  acute  attack  of  appendicitis 
ap})cared.  Ojjeration  totally  relieved  her,  not  only  of  her  recurring 
epigastric  pain  but  of  her  chronic  nausea. 


APPENDICITIS  573 

Cases  of  this  type  are  often  considered  to  be  instances  of  nervous 
indigestion.  A  feeling  closely  allied  to  that  of  nausea  is  the  sense  of 
disagreeable  stomach  emptiness  after  eating,  suggesting  to  the  patient 
that  he  eat  again.  This  symptom,  described  by  Boas  as  a  neurosis 
(see  Gastralgokenosis),  has  occurred  in  a  number  of  cases  of  chronic 
appendicitis  obserAcd  by  the  writer  and  has  been  relieved  by  operation. 

III.  Vomiting  Type. — Recurring  acute  attacks  of  appendicitis  or  acute 
exacerbations  of  a  chronic  inflammation  may  cause  vomiting  for  a  period 
of  several  days  at  a  time,  the  vomited  matters  consisting  either  of  food 
recently  taken  or  of  acid  fluid  characteristic  of  hypersecretion.  The 
amount  of  acid  fluid  is  not  as  copious  as  with  ulcer.  Pain  usually 
accompanies  these  attacks,  having  a  tendency  to  radiate  downward 
and  to  be  more  or  less  continuous  and  uninfluenced  to  any  great  extent 
by  the  taking  of  food. 

Vomiting  with  appendicular  indigestion  does  not  bring  the  same 
degree  of  relief  to  the  patient  as  does  the  vomiting  of  ulcer. 

There  is  a  type  of  chronic  appendicitis  characterized  by  daily  vomit- 
ing continued  over  long  periods  of  time  without  apparent  cause.  Vomit- 
ing may  occur  once  or  twice  a  day  only,  or  may  be  repeated  after  every 
meal,  even  though  the  symptom  extend  over  months  or  years.  In  some 
cases  food  is  ejected  soon  after  eating  without  accompanying  nausea, 
so  that  the  patient  after  an  attack  of  emesis  is  quite  willing  to  eat 
again,  ^^omiting  of  the  entire  meal  is  rarely  observed,  so  that  the  patient 
usually  continues  to  be  of  good  nutrition  and  to  appear  outwardly 
healthy. 

In  other  cases  the  vomiting  is  quite  erratic  and  bears  no  relation  to 
the  meals.  There  may  be  intermissions,  often  of  several  months  or 
more.  In  one  of  the  writer's  cases  an  intermission  of  two  years  occurred. 
Sooner  or  later,  however,  the  symptoms  return  and  cease  permanently 
only  when  the  appendix  is  removed.  Medical  treatment  is  of  no  avail 
in  relieving  the  distressing  symptoms. 

Patients  of  this  group  are  regularly  supposed  to  be  suffering  from 
nervous  indigestion. 

Illustrative  Case. — ^A  history  of  such  a  patient  is  as  follows: 

Mrs.  F.,  aged  thirty-seven  years,  was  well  until  seven  years  ago,  when 
after  a  nervous  upset  she  began  to  suft'er  from  repeated  attacks  of  vomit- 
ing. At  first  vomiting  occurred  only  when  she  was  more  than  ordinarily 
nervous  and  would  cease  when  her  equanimity  was  restored,  but  after 
two  or  three  years  she  began  to  vomit  after  every  meal  and  has  con- 
tinued to  do  so  until  the  present  time.  The  vomiting  is  largely  under 
her  control,  so  that  she  can  post])one  the  emesis  until  a  favorable  oppor- 
tunity occurs.  It  has  not  been  influenced  by  diet,  la\'age,  or  any  medical 
treatment  whatever.     Physical  examination  and  gastric  analysis  were 


574      VARIOUS  DISEASES  AND   THEIR  GASTRIC  RELATIONS 

normal.  At  operation  a  chronic  obliterating  appendix  was  removed, 
followed  by  an  abrnpt  and  permanent  cessation  of  all  previous 
symptoms. 

Vomiting  of  blood  is  not  uncommon,  occurring  in  5  out  of  24  cases 
reported  by  Paterson.  In  12  cases  in  INIoynihan's  series  the  patient 
vomited  over  a  pint  of  blood  at  one  time.  The  combination  of  epigas- 
tric pain  and  hematemesis  so  closely  resemble  ulcer  in  many  instances 
as  to  satisfy  the  most  exact  clinician.  There  has  been  much  discussion 
as  to  the  cause  for  the  bleeding  in  these  cases.  The  hemorrhage  has 
been  ascribed  to  sepsis,  to  embolism  of  an  artery  of  the  stomach  sec- 
ondary to  thrombosis  in  the  omental  branches,  or  to  toxic  conditions 
which  are  at  present  obscure. 

Some  observers  attribute  the  bleeding  to  an  oozing  or  a  weeping  of 
blood  from  the  entire  mucous  membrane  of  the  stomach  without  actual 
loss  of  continuity.  The  writer  believes  than  many  of  the  hemorrhages 
are  due  to  traumatism  of  the  mucous  membrane  of  the  pyloric  canal 
caused  by  the  spasm,  which  results  in  a  lack  of  \'itality  of  tissue  and  the 
production  of  minute  superficial  erosions  due  to  self-digestion. 

l\  .  Gas  Type. — There  is  an  important  group  of  cases  whose  sole  com- 
plaint is  that  of  gas  in  the  stomach  two  or  three  hours  after  eating,  giv- 
ing rise  to  discomfort  or  even  to  pain,  until  relieved  by  free  eructations. 
These  .symptoms  may  appear  in  short  attacks  or  the  distress  may  be 
attended  with  fluctuations  in  its  se^'erity  and  may  be  prolonged  for 
several  days.  There  is  a  lack  of  correspondence  between  the  sense  of 
distention  which  the  patient  experiences  and  the  actual  inflation  of 
the  stomach  by  gas,  as  determined  by  the  physical  examination.  Dis- 
tress from  flatulence  is  more  severe  and  continuous  in  appendix  dys- 
pepsia than  in  the  ulcer  and  is  more  apt  to  be  general  and  unlocalized. 
It  is,  furthermore,  suggestive  that  the  raising  of  a  very  small  amount 
of  gas  will  bring  for  the  time  being  a  complete  relief.  The  distress 
seems  rather  due  to  hypertonus  of  the  stomach  than  to  an  actual 
distention  of  the  viscus  by  gas.  The  history  of  such  a  case  is  as 
follows: 

Mrs.  A.  M.,  aged  twenty-eight  years.  A  nervous  woman  and  sub- 
ject to  t{'mi)orary  uj)sets  of  her  digestion  from  time  to  time,  was  com- 
parati\ely  well  until  three  years  ago,  when  she  began  to  complain  for 
several  weeks  at  a  time  of  gas  in  her  stomach  several  hours  after  eating, 
gi\ing  her  severe  cramp-like  ])ains  which  radiated  ui)ward  to  the  left 
shoulder.    This  was  her  only  coinplaiiit. 

Physical  examination  showed  slight  tenderness  over  McBurney's 
l><>int.  Result  of  gastric  analyses  inconclusive.  Uneventful  recovery 
followed  apjx'iidectomy  without  recurrence  of  the  s}'m{)toms  in  the 
fi\e  years   that    lia\c  elapsed    since   her   operation. 


APPENDICITIS 


bib 


Diagnosis. — It  is  unfortunate  that  in  the  majority  of  instances  the 
examination  of  the  fasting  stomach  and  of  the  test  breakfast  in  chronic 
appendicitis  shows  no  abnormalities  whatever.  The  accompanying 
table  gives  the  total  acidity  of  the  test  breakfast  in  100  cases  of  un- 
complicated chronic  appendicitis: 


Total 
Total 
Total 
Total 
Total 
Total 
Total 
Total 
Total 
Total 


acidity  1  to  10 
acidity  11  to  20 
acidity  21  to  30 
acidity  31  to  40 
acidity  41  to  50 
acidity  51  to  60 
acidity  61  to  70 
acidity  71  to  80 
acidity  81  to  90 
acidity  91  to  100 


4 

cases 

3 

cases 

9 

cases 

16 

cases 

22 

cases 

23 

cases 

15 

cases 

4 

cases 

3 

cases 

1 

case 

00 

cases 

It  will  be  seen  by  this  table  that  hyperacidity  of  over  70  was  present 
in  but  8  per  cent,  and  that  anacidity  (acidity  under  20j  was  present 
in  but  7  per  cent.  These  are  about  the  proportions  seen  in  the  average 
run  of  patients  with  indigestion  as  they  come  consecutively  under 
observation. 

Achylia,  for  example,  occurs  in  about  6  per  cent,  of  all  patients. 
With  chronic  appendicitis  it  occurs  in  7  per  cent.,  showing  there  is  no 
direct  connection  between  these  two  conditions.  The  writer  has  found 
a  hyperacidity  of  70  and  over  in  13.8  per  cent,  of  all  patients  suffering 
from  digestive  disorders,  while  this  complication  occurred  in  8  per  cent, 
of  the  cases  of  chronic  appendicitis,  a  difference  quite  small  though 
probably  suggestive. 

More  important,  however,  is  the  examination  of  the  fasting  stomach 
as  an  indicator  of  chronic  hypersecretion.  In  12  per  cent,  of  the  writer's 
cases  of  chronic  appendicitis,  quantities  of  gastric  juice  of  30  c.c.  or 
more  were  found  in  the  fasting  state.  Amounts  under  30  c.c.  have 
been  disregarded. 

Between  31  and  40  c.c 7  cases 

Between  41  and  50  c.c.    .  2  cases 

Between  51  and  60  c.c 0  cases 

Between  61  and  70  c.c 1  case 

Between  71  and  80  c.c 1  case 

Between  81  and  90  c.c 1  case 


As  this  quantity  (30  c.c.)  was  found  in  a  trifle  less  than  4  per  cent, 
of  all  patients  suffering  from  digesti\e  disorders,  it  is,  therefore,  evident 


57G      VARIOUS  DISEASES  AND  THEIR  GASTRIC  RELATIONS 

that  mild  hypersecretion  is  three  times  more  frequent  with  chronic 
appendicitis  than  in  the  general  run  of  dyspeptic  patients. 

Physical  Signs. — Physical  signs  may  be  totally  lacking.  Repeated 
examinations  of  the  region  of  the  appendix  may  show  at  no  time  the 
slightest  degree  of  tenderness.  If  tenderness  be  present  it  is  usually 
rendered  more  evident  by  palpating  McBurney's  point  after  the  colon 
has  been  moderately  inflated  by  the  rectal  injection  of  air.  Tenderness 
over  the  appendix  was  noted  in  one-third  of  Paterson's  cases.  If  one 
is  content  with  but  a  single  examination,  the  writer  believes  that  the 
number  of  cases  of  appendicitis  without  tenderne^ss  is  far  less  than 
this.  Repeated  examinations  may,  however,  at  some  particular  time 
elicit  a  tenderness  o\'er  the  appendix  that  suggests  the  correct  diagnosis. 
Tenderness  in  the  epigastrium,  usually  somewhat  to  the  right  of  the 
median  line,  occasionally  as  far  down  as  the  level  of  the  umbilicus, 
occurs  almost  constantly,  but  is  not  as  sharply  located  as  is  the  tender- 
ness with  ulcer. 

The  conrse  of  the  disease  is  progressive  with  periodical  exacer- 
bations. During  the  interval  of  the  attacks  more  or  less  discomfort 
and  flatulence  are  present,  so  that  at  no  time  does  the  patient  really 
feel  well. 

Treatment. — There  is  no  medical  treatment  for  appendicular  indi- 
gestion that  is  of  mucli  benefit.  The  symptoms  may  be  temporarily 
relieved  by  the  bland  diet  employed  in  the  convalescence  of  the  ulcer 
cure,  or  by  prolonged  rest  in  bed,  but  the  relief  thus  afforded  is  merely 
temporarj^  It  is  the  persistence  of  the  symptoms  despite  our  best 
medical  care  of  the  patient  that  often  furnishes  us  with  the  correct 
interpretation  of  the  case.  Operation,  therefore,  is  to  be  advised. 
Ordinarily  it  is  the  chronic  obliterating  appendix  that  gives  rise  to  the 
gastric  symptoms,  but  this  is  not  the  form  which  easily  perforates. 
The  operation,  therefore,  is  not  one  of  urgency,  although  it  should  be 
performed  without  unnecessary  waste  of  time.  The  stomach  and  gall- 
bladder should  regularly  be  explored  at  the  time  of  the  operation, 
unless  there  are  definite  reasons  why  this  should  not  be  done. 


DISEASE    OF    THE    GALL-BLADDER    AND    GALLSTONES 

In  many  instances  gallstones  run  a  latent  and  symptomless  course 
and  are  found  at  operation  in  cases  which  have  presented  no  clinical 
evidence  of  their  presence.  In  other  cases  the  symptoms  are  purely 
local,  or  at  least  the  local  symptoms  so  predominate  the  clinical  picture 
that  no  diflicult\-  is  experienced  in  arriving  at  the  correct  diagnosis. 
In   still  other  cases  the  local  manifestations  of  the  disease  may  be 


DISEASE  OF  THE  GALL-BLADDER  AND  GALLSTONES       577 

slight,  often  so  insignificant  as  to  elude  observation,  while  the  bulk 
of  the  symptoms  are  those  of  apparently  gastric  origin. 

Forms.— The  writer  will  only  allude  to  those  forms  of  gall-bladder 
disease  or  gallstones  which  present  the  picture  of  gastric  indigestion. 

1.  The  passage  of  a  stone  into  the  cystic  or  common  duct  results 
in  immediate,  severe,  and  lancinating  pain,  which,  suddenly  appearing 
in  the  epigastrium,  radiates  to  the  right  and  upward  or  to  the  right  side 
of  the  back.  Radiation  to  the  left  may  occur,  but  is  quite  unusual. 
The  pain  is  continuous,  with  periods  of  intense  exacerbation,  often  to 
an  almost  unendurable  degree,  and  is  uninfluenced  by  food,  fluids,  or 
alkalies.  There  may  be  a  distended  bursting  feeling  due  rather  to  the 
character  of  the  pain  than  to  gas.  Vomiting  frequently  occurs  but 
affords  no  relief  to  the  agony,  as  in  ulcer.  The  ejecta  consist  of  recently 
ingested  food,  bile,  and  mucus,  often  of  acid  reaction,  often  the  result 
of  repeated  and  painful  retching.  According  to  W.  J.  Mayo  the  vom- 
itus  more  often  contains  pure  bile  than  does  the  material  vomited  in 
cases  which  might  be  mistaken  for  gallstone  disease. 

Relief  is  only  obtained  by  sufiicient  doses  of  morphine  or  by  the  nat- 
ural termination  of  the  attack.  Should  the  stone  drop  back  into  the 
gall-bladder  or  pass  the  common  duct,  the  cessation  of  pain  is  abrupt; 
but  should  the  stone  become  impacted  in  either  the  cystic  or  common 
duct,  the  pain  may  temporarily  subside,  only  to  be  renewed  with  every 
fresh  excursion  of  the  concretion. 

Jaundice  does  not  occur  with  stone  in  the  cystic  duct  unless  it  be 
impacted  near  the  junction  and  press  upon  and  occlude  the  common 
duct.  Should  the  stone  engage  in  the  common  duct  or  should  the  bile 
ducts  become  inflamed  jaundice  may  result.  Less  frequently  jaundice 
may  occur  from  adhesions  and  kinking  of  the  common  duct,  or  by 
compression  of  the  ampulla  by  swelling  of  the  head  of  the  pancreas. 

During  -the  attack  there  may  be  local  rigidity  of  the  upper  portion 
of  the  right  rectus  and  of  the  right  costal  arch,  with  tenderness  in  the 
region  of  the  gall-bladder.  When  these  signs  are  present  the  diagnosis 
is  quite  evident. 

2.  Should  the  stone  engage  in  the  cystic  duct  the  pain  is  frequenth- 
neither  severe  nor  prolonged,  but  occurs  in  mild  and  repeated  par- 
oxysms— a  clinical  course  quite  indistinguishable  from  that  of  acute 
cholecystitis  next  to  be  described. 

3.  Distention  of  the  gall-bladder  may  result  from  the  impaction  of 
a  small  stone  in  the  cystic  duct,  or  may  be  due  to  acute  cholecystitis, 
or  to  an  acute  exacerbation  of  the  more  chronic  form  of  infection,  which 
results  in  the  swelling  of  the  orifice  or  blocking  the  passage  into  the  duct 
by  mucus.  The  attack  begins  with  an  uneasy  feeling  in  the  stomach, 
as  if  wind  were  there  that  should  be  raised,  although  there  may  be  no 

37 


^ 


57S      VARIOUS  DISEASES  AND   THEIR  GASTRIC   RELATIONS 

demonstrable  inflation  by  the  physical  examination  at  the  time.  The 
patient  will  take  hot  water,  soda,  alkalies,  and  aromatics  withont 
relief.  There  may  be  some  gas  raised  but  the  quantity  is  insignificant 
and  does  not  mitigate  the  distress.  The  pain  then  usually  becomes 
of  a  dull  and  aching  character,  often  described  as  "grinding,"  and  is 
nagging  and  persistent,  and  not  capable  of  relief  in  any  way  except  by 
morphine  or  codeia.  These  symptoms  seem  regularly  due  to  gastric 
spasm  reflexly  induced  by  the  irritative  lesion  in  the  gall-bladder. 
^'()miting  may  occur,  the  ejecta  consisting  mainly  of  recently  ingested 
food  without  definite  characteristics. 

4.  In  other  cases  painful  gaseous  distention  may  occur  from  time  to 
time  without  relation  to  meals  or  other  apparent  cause.  Relief  is  reg- 
ularly afforded  for  the  time  being  by  carminatives,  which  succeed  in 
raising  the  gas  in  large  quantities,  with  immediate  relief.  It  is  rather 
characteristic  for  these  paroxysms  to  occur  during  the  early  part  of 
the  night,  so  that  the  patient  will  sit  uj)  for  several  hours  attempting 
in  various  ways  to  raise  the  gas  and  to  procure  relief.  Many  cases 
of  flatulent  dyspepsia  seen  in  dispensaries  belong  to  this  group  of 
cases. 

5.  There  is  a  close  association  between  gall-bladder  disease  and 
achylia.  Twenty-two  per  cent,  of  the  writer's  cases  of  achylia  were 
associated  with  gall-bladder  disease  or  gall■^tones,  while  in  the  gall- 
bladder cases  achylia  was  present  in  30  per  cent.  The  functional 
forms  of  achylia  and  those  due  to  chronic  gastric  catarrh  run  a 
painless  course.  Achylia  accompanied  by  pain  is  regularly  indicative 
of  an  organic  complication.  Especially  should  be  considered  in  these 
cases  gastric  cancer,  gall-bladder  disease,  chronic  appendicitis,  and 
angina  abdominalis. 

6.  Of  the  writer's  series  of  gall-bladder  and  gallstone  cases  hyper- 
acidity was  found  in  30  per  cent.  Functional  hyperacidity  is  not 
accompanied  by  either  heart-burn  or  pain,  and  the  occurrence  of  either 
of  these  symptoms  should  suggest  an  organic  origin,  especially  ulcer, 
cancer,  gall-bladder  disease,  or  chronic  appendicitis. 

7.  With  disease  of  the  gall-bladder  and  with  gallstones  a  protective 
spa.sm  of  the  pylorus  may  be  induced,  resulting  in  recurring  epigastric 
pain  or  in  the  symjitoms  of  hypersecretion.  There  may  be  thus  a  close 
mimicry  between  gastric  ulcer,  gallstones,  and  chronic  appendicitis,  so 
that  in  a  doubtful  case  it  is  well  not  to  express  too  positive  an  o})inion. 
The  diagnosis  is  rendered  still  more  difficult  by  the  i)()ssibility  of  two 
or  all  of  these  conditions  being  associated  in  the  same  patient.  No 
surgical  cx])lorati()n  ])erformed  for  the  sake  of  determining  the  origin 
of  recurring  (epigastric  ])ain  is  ('()m])lete  iniless  the  stomach,  duodenum, 
appendix,  and  gall-bliiddcr  be  (•xi)l()r('(l. 


ARTERIOSCLEROSIS  57'J 


ARTERIOSCLEROSIS 


Arteriosclerosis  is  of  common  occurrence  in  those  of  advancing  years 
as  well  as  in  younger  subjects  in  whom  the  combination  of  alcohol 
and  hard  work,  gout,  lead  poisoning,  syphilis,  and  various  toxemias 
from  infectious  disease,  errors  in  metabolism,  and  toxic  absorption 
from  intestinal  stasis,  may  be  demonstrated  to  be  predisposing  or  pre- 
cipitating factors.  In  other  patients  the  arterial  disorder  may  appear 
as  an  evidence  of  premature  senility  or  as  the  result  of  causes  at  present 
obscure.  It  is  not  within  the  scope  of  this  section  to  deal  with  the  causes 
of  or  the  symptoms  produced  by  arterial  disease  in  general,  but  to 
confine  the  discussion  to  the  various  conditions  of  the  stomach  produced 
by  such  a  malady,  and  to  describe  the  symptoms  by  which  an  arterio- 
sclerotic origin  of  the  complaint  may  be  recognized  or  suspected. 

Etiology. — There  seems  to  be  but  little  relationship  between  the 
development  of  the  arterial  disease  on  the  one  hand  and  the  symptoms 
which  it  produces  on  the  other.  Gastric  symptoms  may  be  present  in 
cases  in  which  the  arteries  are  apparently  but  slightly  in^'olved  and 
totally  lacking  in  the  advanced  forms  of  the  disease  so  commonly  seen 
in  our  hospital  wards. 

In  many  of  the  cases  that  are  apparently  latent  as  far  as  symptoms 
of  indigestion  are  concerned,  it  is  probable  that  atrophy  of  the  mucosa 
with  an  accompanying  chronic  interstitial  inflammation  is  present  with- 
out producing  symptoms  of  any  indigestion  whatever.  Achylia  occurs 
in  GO  per  cent,  of  patients  over  fifty,  whether  symptoms  of  gastric 
disorder  are  present  or  not.  The  changes,  productive  and  atrophic, 
in  the  gastric  mucosa  are  more  probably  lesions  associated  with 
arterial  sclerosis  than  directly  due  to  it.  The  only  suggestive  symp- 
tom produced  by  this  phase  of  the  disorder  is  morning  diarrhea.  A 
full  description  of  these  cases  is  given  under  the  heading  of  iVchylia, 
page  496. 

Local  thickening  of  the  wall  of  any  of  the  gastric  arteries  may  lead 
to  blocking  of  the  blood  suppl}-  of  a  portion  of  the  stomach,  so  that 
the  affected  area  is  eroded  by  gastric  digestion  and  ulceration  results. 
This  intoward  event  would  occur  far  more  frequently  than  it  does 
were  it  not  for  the  tendency  toward  achylia  as  age  advances. 

Miliary  aneurysms  produced  by  local  atheromatous  degeneration  may 
occur  in  the  course  of  any  of  the  gastric  arteries  and  may  lead  to  sudden 
and  usually  fatal  hematemesis.  The  production  of  the  aneurysm  is 
favored  by  ulceration  of  the  overlying  portion  of  the  mucosa.  The 
peptic  ulcer  may  or  may  not  have  given  previous  symptoms  of  its 
presence.     With  the  history  of  preceding  pain,  followed  by  profuse 


580     VARIOUS  DISEASES  AND  THEIR  GASTRIC  RELATIONS 

hemorrhage,  the  diagnosis  from  the  ordinary  chronic  ulcer  and  erosion 
of  a  branch  of  the  gastric  artery  is  quite  impossible.  If  the  previous 
history  of  ulcer  cannot  be  elicited,  a  differential  diagnosis  from  rupture 
of  esophageal  varices,  the  result  of  cirrhosis  of  the  liver,  is  often  difficult, 
especially  as  cirrhotic  patients  are  subject  by  reason  of  alcohol  and  their 
mode  of  living  to  widespread  arterial  disease. 

An  arteriosclerotic  ulcer  may  be  suspected  if,  preceding  the  hemor- 
rhage, there  be  the  history  of  epigastric  pain  or  sudden  attacks  of  flat- 
ulence, occurring  whenever  the  patient  walks  after  his  meal  and  which 
do  not  occur  if  he  rests  after  eating. 

In  advanced  arteriosclerosis  with  signs  of  failing  heart  and  Aenous 
congestion,  anorexia,  vomiting,  and  the  pain  of  hepatic  engorgement 
may  occur.  These  are  the  symptoms  common  to  all  cardiac  cases  in 
the  stage  of  decompensation. 

In  other  patients  gastric  symptoms  may  appear  for  a  considerable 
time  before  characteristic  symptoms  of  arteriosclerosis  develop,  and 
may  be  divided  into  two  groups,  according  to  whether  flatulence  or 
pain  constitutes  the  predominant  symptom. 

Symptoms. — Gas  Type. — Attacks  of  flatulence  may  occur  regularly 
after  eating,  appearing  usually  at  the  height  of  digestion  with  some 
abruptness  and  subsiding  gradually  as  gastric  digestion  wanes.  In 
some  instances  the  attack  is  abruptly  terminated  by  the  eructations 
of  gas  which  instantly  relieve  the  distress.  The  symptoms  do  not 
appear  with  every  meal  and  for  days  there  ma}^  be  freedom  from  the 
attacks. 

Fig.   121 


Pain  chart  of  a  patient  with  angina  abdominalis.  showing  two  types  of  pain,  one  type  ooming  on 
while  walking  and  instantly  relieved  by  stopping,  the  other,  appearing  diiring  the  height  of  gastric 
digestion,  relieved  by  raising  gas. 


The  paroxysm  may  be  precipitated  by  exercise,  especially  walking 
after  the  meal.  The  gas  is  often  in  large  amounts  and  produces  as  much 
oppression  in  the  chest  as  in  the  abdomen.  This  oppression  is  often 
so  extreme  that  the  patient  has  to  stop  whatever  he  is  doing  until  he 
can  raise  the  gas,  after  which  he  is  not  apt  to  suffer  until  after  some 
succeeding  meal.  The  attacks  are  not  apparently  influenced  in  the  least 
by  the  character  of  the  food  that  is  eaten.  Nervousness  almost  regularly 
makes  the  gas  worse.  In  other  instances  the  attacks  occur  whenever 
the   patient   walks  after  eating.      If  he  sits  quietly  or  rests  he  is  free 


ARTERIOSCLEROSIS  5S1 

from  all  distress,  but  upon  moving  around,  walking  or  undressing,  or 
occasionally  induced  hy  changes  in  temperature,  an  attack  ([uickly 
supervenes.  There  is  in  the  majority  of  the  cases  the  background  or 
arteriosclerosis  in  some  more  or  less  characteristic  form. 

Illustrative  Cases. — ^The  following  histories  may  be  cited  as  ex- 
amples of  the  gaseous  form  of  arteriosclerosis. 

T.  B.,  aged  sixty  years,  was  well  until  three  years  ago,  when  he  began 
a  series  of  attacks  of  pain  over  the  heart,  which  were  so  intense  that 
during  an  attack  sweat  would  stand  out  on  his  forehead.  During  the 
attacks  he  feared  he  would  die.  About  this  time  he  began  to  be  troubled 
by  flatulence,  not  so  much  during  the  day  as  after  dinner,  when  he  will 
feel  uneasy  and  walk  about  in  a  nervous  state  for  two  or  three  hours 
in  extreme  discomfort.  He  will  then  raise  odorless  gas  in  explosive 
quantities  and  feel  completely  relieved.  Nervousness  makes  the  gas 
worse,  but  he  has  found  that  on  a  varied  diet  it  is  not  worse  than  when 
his  food  is  restricted.  His  chief  complaint  is  of  recurring  attacks  of 
flatulence  after  dinner.  Physical  examination  showed  obvious  arterio- 
sclerosis, slight  hypertrophy  of  the  left  ventricle,  with  a  ringing  second 
sound,  tension  high.  Patient  died  a  few  months  later  during  an  attack 
of  angina  pectoris. 

F.  E.,  aged  sixty  years,  has  always  been  well,  but  under  much 
anxiety  and  strain  for  many  years.  His  present  ailment  began  six  or 
seven  years  ago,  when  he  suffered  from  gas  coming  after  meals,  especially 
if  he  made  any  exertion,  as  in  walking  or  undressing,  or  subjected 
himself  to  rapid  changes  of  temperature.  The  gas  collects  suddenly 
and  in  large  amounts,  and  creates  a  feeling  of  oppression  in  the  upper 
abdomen  and  in  the  thorax,  at  times  pressing  upon  the  nerves  of  the 
right  shoulder.  When  the  gas  forms  he  has  to  stop  until  he  can  raise 
it,  and  as  soon  as  he  is  rid  of  it  he  feels  absolutely  comfortable  and  can 
play  eighteen  holes  of  golf.  His  wife  notices  that  anything  that  makes 
him  nervous  increases  the  frequency  and  the  severity  of  the  attacks. 
There  has  been  no  history  of  precordial  pain. 

Examination  showed  a  moderate  hypertrophy  of  the  left  ventricle 
and  an  accentuated  second  aorta  sound,  faint  systolic  murmur  at  the 
apex;  arteries  moderately  thickened,  tension  210  mm.  Hg.  Test  break- 
fast showed  achylia.  On  the  day  following  the  examination  patient 
appeared  in  great  distress,  saying  that  an  attack  had  suddenly  come  on 
while  in  the  elevated  train,  so  that  it  was  with  great  difficulty  that  he 
was  able  to  leave  the  train  and  take  a  cab  to  his  office.  Examination 
showed  well-marked  inflation  of  the  stomach.  A  tube  was  passed  and 
a  large  quantity  of  gas  was  expelled  under  great  pressure,  with  immedi- 
ate relief  to  his  distress.  Within  a  few  days  characteristic  attacks  of 
angina  developed,  in  one  of  which  he  suddenly  died. 


582     VARIOUS  DISEASES  AND  THEIR  GASTRIC  RELATIONS 


Pain  Type.  —  Recurring  epigastric  pain  due  to  arteriosclerosis  is 
(leseril)e(l  under  the  term  of  "angina  abdominalis."  The  pathogenesis 
of  the  })ain  is  often  obscure.  By  some  the  pain  is  attributed  to  hyper- 
esthesia of  the  sympathetic  plexus  that  overlies  the  abdominal  aorta, 
while  by  others  the  pain  is  ascribed  to  a  distal  localization  from  painful 
distention  of  the  aortic  ring  or  ascending  portion  of  the  thoracic  aorta. 

The  generally  accepted  view  is  that  epigastric  pain  is  analogous  to 
the  pain  of  intermittent  claudication  and  is  due  to  a  diminished  blood 
supply  from  vascular  colic  (Gefass  Koliken  of  Nothnagel)  of  the  affected 
artery. 

For  the  analogy  to  be  complete  one  must  imagine  an  increased 
activity  in  the  gastjric  wall  itself,  during  increased  peristalsis  following 
eating.  This  reason  is  probably  sufficient  to  explain  the  occurrence 
of  ])ain  after  hearty  meals,  but  does  not  explain  the  connection  between 
pain  and  exercise  requisite  to  produce  it,  unless  we  surmise  that  exercise 
raises  blood  pressure,  producing  vasoconstriction  in  the  splanchnic 

Fig.   122 


Pain  cliait  of  a  patient  witli  angina  abdominalis,  showing  the  gradual  onset  of  distress  increasing 
toward  the  height  of  gastric  digestion,  then  slowly  subsiding  even  though  the  i)atieut  rests  quietly 
after  eating. 

area,  and  narrows  the  already  sclerotic  bloodvessels  to  produce  a  com- 
parative ischemia  of  the  stomach  wall.  PaP  regards  vascular  crises 
to  be  due  to  arterial  spasm  producing  cerebral  cardiac  or  abdominal 
symptoms  as  well  as  the  paroxysmal  phenomenon  known  as  internal 
claudication.  According  to  Pal  a  rise  of  blood  pressure  precedes  and 
accompanies  the  crisis  of  pain,  and  in  a  few  of  his  cases  spasm  or  con- 
traction of  the  retinal  arteries  could  be  demonstrated. 

The  group  of  arteriosclerotic  ])atients  })resenting  ei)igastric  ])ain  as  a 
prominent  feature  may  be  subdi\ided  into  three  clinical  groups. 

1 .  A  dull  aching  or  throb})ing  pain  may  be  experienced  about  one  hour 
after  eating,  which  is  not  due  to  gas.  As  a  rule  the  heartier  the  meal 
the  greater  the  distress.  It  is  probable  that  in  these  cases  the  narrowed 
arteries  are  able  to  carry  sufficient  blood  to  the  stomach  for  its  require- 
ments in  the  quiescent  state,  l)ut  are  unable  to  meet  the  increased 
demands  of  j)hysiological  congestion  during  the  digesting  state.  1  )uriiig 
active  peristalsis  the  symptoms  of  ischemia  become  apparent  and  the 
(•()ii(htioii  is  tlierefore  akin  to  that  of  intermittent  claudication. 

'  Gefiisscrisen,  Leip.sic,  1905. 


A RTERIOSCLEROSIS 


583 


2.  There  may  be  no  pain  after  eating  unless  the  })atient  takes  exereise 
after  his  meal.  This  is  the  most  common  chnical  form  of  the  ailment. 
If  the  patient  sits  quietly  after  his  dinner  he  is  quite  comfortable;  if 
he  walks  he  experiences  severe  pain  in  the  lower  thorax  and  abdomen, 
often  radiating  upward  to  the  throat  and  down  the  arms  so  that  he 
will  be  obliged  to  stop.    After  resting  a  short  time,  varying  from  thirty 


Fia.  123 


Pain  chart  of  a  patient  with  angina  abdominaha.    The  pain  conies  on  whenever  the  patient 
exercises  and  is  at  once  relieved  by  rest. 

seconds  to  a  couple  of  minutes,  the  pain  will  disappear  and  he  ma}' 
then  be  able  to  walk  without  distress  for  a  number  of  miles.  In  some 
cases,  however,  the  symptoms  reappear  after  he  has  gone  two  or  three 
blocks,  so  that  he  has  again  to  rest  until  the  paroxysm  is  past.  This 
pain  may  be  relieved  by  raising  gas,  although  complete  relief  is  not 
usually  so  obtained. 

Fig.   124 


Pain  chart  of  a  patient  with  angina  abdominalis.    The  pain  is  induced  by  walking,  but  after  relief 
from  rest  does  not  reappear. 

Illustrative  Case. — A  characteristic  history  is  as  follows: 
C.  T.  P.,  aged  seventy-six  years,  for  the  past  few  years  has  com- 
plained of  gas  on  the  stomach  whenever  he  walks  after  a  meal,  although 
he  has  enjoyed  long  intervals  of  freedom.  For  the  past  year  he  has  found 
that  if  he  walks  within  two  hours  after  a  meal  he  will  be  seized  with  a 
sudden  severe  pain  in  the  lower  thorax  and  abdomen  so  that  he  will 
have  to  siand  quietly  for  a  minute  or  two  until  the  paroxysm  has  passed 
and  then  he  can  walk  two  or  three  miles  without  distress.  The  heart 
was  apparently  normal  in  size  and  action  although  on  one  occasion 
there  was  a  slight  approach  to  the  bigeminal  form  of  pulse.  ^YeII- 
marked  systolic  at  apex,  second  aortic  accentuated,  arteries  some- 
what thickened,  blood  pressure  190,  systolic  murmur  heard  down  the 
abdominal  aorta  transmitted  to  the  peripheral  arteries.    The  attacks 


584      VARIOrS  DISEASES  AND  THEIR  dASTRIC   RELATIONS 

decreased  in  number  and  se\erity  by  appropriate  medication.  Death 
from  angina  occurred  within  the  year. 

3.  A  patient  may  be  suddenly  seized  by  sharp  lancinating  or  crush- 
ing paroxysmal  pains  which  recur  at  short  intervals,  often  every  fifteen 
or  twenty  minutes,  and  last  but  a  few  moments  at  a  time.  Slight 
icterus  has  been  observed  at  times,  suggesting  the  possibility  of  biliary 
colic.  A  succession  of  paroxysmal  pains  constitutes  an  attack  which 
may  last  for  several  days  and  be  followed  by  a  period  of  comparati\'e 
freedom.  The  attacks  are  often  induced  by  worry  or  nervous  excite- 
ment, and  may  appear  during  the  night.  During  the  height  of  pain 
dyspnea,  moderate  cyanosis,  and  Che^aie-Stokes  respiration  may  be 
present.  In  a  few  of  the  cases  a  moderate  icterus  has  been  observed. 
These  attacks  are  probably  true  angina  with  radiation  toward  the 
epigastrium. 

Diagnosis. — In  all  forms  of  arteriosclerosis  there  is  usually  a  fore- 
ground of  general  symptoms  due  to  the  arterial  disease  which  may  be 
detected  by  close  observation.  The  physical  examination  in  hospital 
cases  is  not  of  as  much  importance  as  one  would  expect,  because 
evidences  of  arteriosclerosis  are  so  extremely  common  in  those  who 
have  passed  into  the  period  of  middle  age.  If  it  be  found  that  a  sudden 
rise  in  blood  pressure  occurs  preceding  a  paroxysm  the  inference 
is  quite  convincing.  Steadily  high  blood  pressure  while  indicating  a 
probable  arterial  cause  for  the  hypertension  does  not  necessarily  indicate 
that  the  gastric  symptoms  in  a  given  case  are  of  arteriosclerotic  origin. 
More  important  in  the  diagnosis  is  the  fact  that  the  symptoms  are 
frequently  induced  or  aggravated  by  exertion,  and  in  the  majority  of 
cases  no  complaint  is  made  if  the  patient  rests  quietly  after  his  meal. 
This  same  relation  between  painful  symptoms  and  exercise  may  occur 
with  perigastric  adhesions,  and  the  fact  that  relief  follows  the  rest 
of  one  or  two  minutes  in  the  sclerotic  cases  should  settle  the  diagnosis 
with  comparative  ease. 

Hardly  less  significant  is  the  effect  of  medication  in  arteriosclerotic 
disorders.  There  are  but  few  instances  of  angina  abdominalis  in  which 
the  symptoms  are  not  noticeably  relieved  by  the  nitrites  or  by  diuretin. 

The  gastric  analysis  in  the  writer's  cases  has  almost  regularly  shown 
achylia  to  exist,  but  the  number  of  examinations  of  the  gastric  contents 
is  small  compared  with  the  number  of  patients  in  whom  the  clinical 
diagnosis  of  angina  abdominalis  has  been  made,  as  the  writer  regards 
the  iiresence  of  arterial  disease  that  gives  sym-ptoms  a  positive  contra- 
indication to  the  passage  of  the  tube. 

Prognosis. — The  prognosis  is  bad  for  ultimate  recovery,  although 
the  duration  of  the  disease  may  be  uncertain.  Relief  may  be  expected 
to  some  extent  at  least  from  treatment,  but  the  possibility  of  fatal 
angina  at  any  time  renders  the  outlook  distressingly  uncertain. 


ARTERIOSCLEROSIS  585 

Treatment. — The  treatment  is  that  of  arteric^sclerosis  in  general,  the 
details  of  which  need  not  be  gone  into  fully  in  this  connection.  Tea, 
coffee,  and  tobacco  need  not  be  totally  eliminated  but  should  be  decid- 
edly restricted.  Whether  or  not  alcohol  is  to  be  totally  interdicted  is  to 
be  decided  upon  the  merits  of  each  individual  case.  In  general,  total 
abstinence  is  desirable,  but  in  those  who  are  accustomed  to  the  daily 
use  of  alcohol  with  their  meals,  whisky  and  water  may  be  permitted 
at  dinner,  although  the  allowance  should  be  small.  Alcoholic  indul- 
gence, except  at  meals,  should  be  absolutely  forbidden. 

Exercise  should  be  taken  in  moderation  and  while  extreme  restriction 
is  generally  inadvisable,  strenuous  exertion,  hurrying  for  trains  and 
rapid  running  or  walking  should  be  avoided.  Exercise  during  the  period 
of  pain  is  contraindicated.  Many  patients  will  push  on  no  matter  how 
severe  may  be  their  distress,  hoping  to  walk  it  off.  This  is  never 
advisable. 

The  diet  should  be  simple,  nutritious,  and  not  too  bulky  at  any  one 
meal.  Hearty  dinners  are  often  provocative  of  nocturnal  distress,  and  in 
some  instances  the  attacks  may  be  minimized  by  the  adoption  of  a  light 
supper  as  the  last  meal  of  the  day  in  the  place  of  the  conventional 
dinner. 

Exercise  after  meals  must  be  taken  sparingly  and  should  cease  the 
moment  distress  appears,  until  the  paroxysm  is  past.  The  bowels 
should  be  carefully  regulated  and  a  morning  aperient  draught  is  fre- 
quently of  service  in  diminishing  the  frequency  and  severity  of  the 
attacks. 

Medical  Treatment. — We  possess  in  diuretin  a  remedy  which  is  followed 
by  the  most  excellent  results  in  the  gastric  form  of  arteriosclerosis, 
and  which  frequently  acts  almost  as  a  specific  in  controlling  the 
attacks. 

Diuretin  or  the  double  salicylate  of  theobromine  and  sodium  is  best 
given  in  aromatic  water.  In  syrup  it  is  apt  to  deposit,  while  in 
powders  it  is  liable  to  decompose  in  a  short  time.  The  ordinary  dose 
is  grains  vij-x,  three  times  a  day,  occasionally  pushed  to  grain  xv 
doses  at  these  intervals,  and  may  be  given  in  the  form  of  the  following 
prescription : 

I^ — Diuretin 3v 

Aq.  cinnamoni oiv 

M.    Sig. — Teaspoonful  in  water  three  times  a  day  after  meals. 

Or  the  following  prescription: 

I^ — Theobromine  sodium  salicylat 5v  3ij 

Muoilag.  acaciaj 5ss 

Aq.  menth.  pip ad     5iv 

M.     Sig. — Shake  well.    Teaspoonful  in  water  three  times  a  day  after  eating. 


580      VARIOl'S  DISEASES  AND  THEIR  GASTRIC  RELATIONS 

The  only  objection  to  its  use  is  the  costHness  of  the  drug. 

Tincture  of  strophanthus  in  5-minim  doses  seems  to  sustain  the 
effect  of  diuretin  after  this  drug  has  been  discontinued,  and  encour- 
aging results  often  follow  its  use.  The  arterial  dilators,  nitroglycerin, 
sodium  nitrite,  and  erythrol  tetranitrate,  are  serviceable  in  reducing 
blood  pressure  and  in  controlling  the  tendency  toward  vascular  colic. 
Nitroglycerin  by  reason  of  its  rapid  action  is  eminently  useful  to  check 
the  paroxysm  when  acute  symptoms  appear.  The  patient  should  regu- 
larh'  carry  with  him  tablets  of  grain  ttt,  care  being  taken  that  they  are 
not  too  old;  and  1  to  3  of  these  may  be  taken  at  the  time  of  the  attack. 
The  action  of  nitroglycerin  seems  to  be  more  marked  and  constant 
when  the  patient  is  taking  steady  doses  of  diuretin.  The  iodides  or 
sodium  nitrite  may  be  given  (grain  |-j),  preferably  in  alkaline  solu- 
tion. The  action  of  the  latter  is  slower  though  more  pronounced 
than  that  of  nitroglycerin.  The  drug  may  be  well  combined  with 
the  bromides  or  with  Hoffman's  anodyne,  as  in  the  following  pre- 
scription : 

I^ — Sodii  nitril.       .  grt*.  viij 

Spt.  a'theris  co 5ij 

Elix.  aurantii 5'j 

Liq.  amnion,  acet ad  5Jv 

M.  Sig. — 3ij  every  three  to  four  hours  in  water. 

Tablets  of  erythrol  tetranitrate  [grain  ^  (Merck)]  may  })e  given 
three  or  four  times  a  day,  and  are  said  to  exert  a  sustained  action  in 
reducing  blood  pressure.  The  writer  has,  however,  been  disappointed 
in  this  medication  and  regards  it  inferior  to  the  other  forms  of  treatment. 
The  iodides  constitute  the  standard  form  of  treatment,  but  the  dis- 
advantage of  their  prolonged  use  in  producing  iodism  is  obvious.  The 
syrup  of  hydriodic  acid  (Gardner's)  may  be  substituted,  although 
somewhat  less  efficient.  If  iodides  are  given  they  must  be  well  diluted, 
and  preferal^ly  combined  with  a  carminative  such  as  tincture  of  cap- 
sicum or  ginger,  as  in  the  following  prescription: 

I^ — Kah  lodi 5ss 

Fid.  ginger  (.soluble) 3ss 

SyruptuH  siiiii)! 5«s 

Aq.  cinnamoiiii ad  5'V 

M.     Sig. — 5j  •■oiitaiiis  7',  grains  potassiiun  iodide. 

Sajodiii  ill  7^-grain  doses  may  be  gi\eii  in  (•ai)sules  four  times  a  day, 
and  has  frequently  been  of  service. 


PLATE    XV 


Fi.j,    ] 


Lane's  Kink.  Plate  taken  six  hours  after  the  first  bismutli  meal  and 
five  nninutes  after  the  second  bisnnuth  meal,  showing  the  advance  column 
of  bismuth  in  the  terminal  portion  of  the  ileum.  The  recently  filled 
stomach  is  moderately  atonic.       (Radiologist,   Dr.   Leaming.) 


Fig.   2 


Lane's  Kink.  Plate  taken  six  hours  after  bismuth  meal,  showing 
advance  of  column  of  bismutli  in  the  lower  ileum.  (Radiologist,  Dr. 
Leaming.) 


DUODENOJEJUNAL  KINKS  587 

DUODENOJEJUNAL   OBSTRUCTION  BY  KINKS   AND  ARTERIO- 
MESENTERIC   CONSTRICTION 

Pain  and  regurgitation  of  duodenal  eontents  occur  whenever  there 
is  obstruction  in  the  duodenum  below  the  ampulla.  These  symptoms 
may  result  from  cicatricial  contraction  following  ulceration,  although 
such  a  low-lying  ulceration  is  rare.  jMore  commonly  moderate  chronic 
obstruction  is  found  in  the  terminal  portion  of  the  duodenum,  or  at 
the  duodenojejunal  junction,  and  may  be  caused  in  one  of  two  ways: 
(1)  by  duodenojejunal  kinks,  and  (2)  by  arteriomesenteric  constriction. 
The  symptoms  produced  by  both  of  these  conditions  are  practically 
identical,  and  there  seems  to  be  no  way  at  the  present  time  of  differ- 
entiating between  them.  Moreover,  the  mechanical  factors  that  con- 
tribute to  the  obstruction  are  in  great  measure  the  same,  so  that  the 
same  surgical  treatment  is  required  in  both  instances. 

Duodenojejunal  Kinks. — The  tendency  for  viscera  to  drop  from 
gravity,  results  in  the  formation  of  thickened  bands  in  the  mesentery 
which  represent  nature's  effort  to  reinforce  weak  points.  Unfortunately, 
this  conservative  process  is  not  uniform  nor  sufficient  in  some  instances 
to  overcome  the  tendency  to  traction  by  gravitation,  so  that  kinks 
are  produced  that  lead  to  more  or  less  obstruction. 

The  most  important  vulnerable  point  is  at  the  junction  of  the  duode- 
num with  the  jejunum,  a  point  which  is  usually  held  up  by  a  peritoneal 
band  fixing  the  end  of  the  duodenum,  while  the  jejunum  is  unsupported 
at  its  commencement.  Normally  a  distinct  angulation  at  this  point 
does  not  exist,  but  occasionally  the  jejunum  is  dragged  down  vertically, 
producing  a  sharp  kink.  The  drag  or  traction  power  is  usually  due  to 
the  dropping  of  other  viscera,  especially  the  lower  ileum,  which  becomes 
loaded  should  there  be  any  delay  in  the  passage  of  its  contents  into  the 
cecum,  so  that  the  heavy  end  coils  of  the  ileum  drag  upon  the  mesentery 
and  pull  down  the  whole  of  the  small  intestine.  In  consequence  the 
jejunum  is  dragged  vertically  downward  and  a  sharp  angulation  on 
the  duodenojejunal  junction  is  produced.  The  primary  cause  for  the 
angulation,  therefore,  is  ileal  stasis,  presumably  due  to  ileal  kinks. 
Lane's  ileal  kink  is  the  term  applied  to  a  pathological  bend  in  the  ter- 
minal six  inches  of  the  ileum,  producing  a  sharp  angulation  which  is 
complicated  by  thickening  of  the  mesentery  and  adhesions  of  the  two 
arms  of  the  angulation  to  each  other,  eventuating  in  a  definite 
intestinal  stasis. 

The  mechanical  result  of  the  kink  is  a  dilatation  of  the  proximal 
portion  of  the  duodenum,  which  ultimately  becomes  congested  and 
occasionally  even  ulcerated.     According  to  Jordan, ^  who  has  given  us 

'  British  Med.  Jour.,  June  1,  1912. 


5SS     VARIOUS  DISEASES  AND   THEIR  GASTRIC  RELATIONS 

the  greatest  and  most  convincing  description  of  the  condition  studied 
radiographically,  the  duodenum  ma}'  writhe  vigorously  for  as  long  as 
nine  hours  to  force  the  bismuth  emulsion  past  the  point  of  angulation. 
The  stomach  also  contracts  in  these  cases  as  though  struggling  against 
abnormal  obstruction,  although  the  bismuth  meal  passes  freely  through 
the  pylorus. 

Symptoms. — Pain  and  vomiting  are  commonly  observed,  the  pain 
being  due  to  the  efforts  of  the  duodenum  to  empty  itself  during  the 
period  of  its  greatest  distention.  Vomiting  may  occur  at  this  time  and 
presents  the  characteristics  in  some  instances  of  duodenal  regurgita- 
tion, the  ejecta  being  copious,  bile-stained,  and  occasionally  containing 
pancreatic  ferments.  The  symptoms  are  not  permanent  but  gradually 
pass  away  when  the  patient  lies  down  and  the  downward  traction  on 
the  jejunum  ceases.  A  few  days'  rest  in  bed  will  usually  be  sufficient 
for  the  time  being  to  effect  temporary  cure;  the  discomfort,  however, 
reappears  after  the  reassumption  of  the  upward  posture,  especially 
toward  the  close  of  the  day.  -Pain  during  the  late  afternoon  or  e\en- 
ing  is  regularly  worse  than  that  in  the  morning.  Intermissions  in  the 
se\'erity  of  the  complaint,  or  even  complete  absence  from  all  discom- 
fort for  a  number  of  days  may  occur  during  the  course  of  the  malady. 
Jordan  (loc.  cit.)  has  reported  an  interesting  case  with  radiographic 
findings  so  instructive  and  con^'incing  that  it  may  be  well  to  cite  it  in 
this  connection. 

A  single  woman,  aged  thirty-two  years,  had  suffered  from  dj'spepsia 
troubles  for  one  and  a  half  3'ears,  and  during  this  time  had  lost  nearly 
14  pounds  in  weight.  There  were  loss  of  appetite  and  nausea,  but  no 
vomiting.  She  complained  of  pain  in  the  region  of  the  gall-bladder, 
saying  that  she  felt  there  was  something  distended  or  gorged  in  that 
region  which  would  burst  if  she  tapped  it.  The  distended  feeling  was 
also  felt  in  the  corresponding  point  of  the  back.  The  attacks  of  pain 
were  intermittent  and  were  oftentimes  absent  for  days.  The  patient's 
general  condition  was  characteristic  of  intestinal  stasis.  She  was  sick 
and  depressed;  her  hands  and  feet  were  cold,  her  complexion  muddy 
in  contrast  to  her  former  clear  skin;  the  breasts  showed  the  nodular 
condition  of  chronic  mastitis;  the  stomach  was  elongated  and  dropped, 
but  normal  in  other  respects.  Bismuth  emulsion  passed  through  the 
pylorus.  The  duodenum  was  found  to  be  much  elongated  and  dilated 
to  more  than  double  its  normal  diameter,  except  the  first  part,  wliich 
seemed  to  be  the  seat  of  cicatricial  contraction. 

"The  duodeiuim  was  undergoing  ])()werful  peristaltic  contractions, 
amounting  to  strong  writhing  movements;  this  continued  for  seven 
or  eight  minutes  without  a  particle  of  bismuth  being  able  to  pass 
through    into   the   jejunum.    The   writhing   duodenum  was   observed 


DUODENOJEJ UNA  L  KINKS 


589 


and  demonstrated  to  two  colleagues  without  difficulty,  for  the 
duodenum  was  completely  isolated  in  the  fluorescent  screen  picture, 
the  rest  of  the  bismuth  being  contained  in  the  cardiac  end  of  the 
stomach.  At  the  end  of  seven  or  eight  minutes,  with  a  very  powerful 
duodenal   contraction,   a   large  mass  of  bismuth  emulsion  was  sent 


Fluorescent  screen  tracing  (reduced  in  size)  of  the  duodenum  and  pylorus  in  a  woman,  aged  thirtj-- 
two  years,  with  the  typical  symptoms  and  signs  of  intestinal  stasis.  Taken  on  the  couch.  The  duode- 
num is  half  as  long  again  and  more  than  double  the  width  of  a  normal  duodenum.  For  seven  or  eight 
minutes  the  duodenum  was  observed  undergoing  vigorous  "writhing"  contractions,  in  a  vain  endeavor 
to  force  its  contents  into  the  jejunum  through  the  kink  at  the  duodenojejunal  junction.  After  seven 
or  eight  minutes  a  very  powerful  contraction  of  the  duodenum  forced  a  large  mass  of  bismuth  emul- 
sion through  suddenly  into  the  jejunum,  and  the  bismuth  forthwith  began  to  course  rapidly  through 
the  coils  of  the  small  intestine.  The  small  figure  in  the  right-hand  corner  represents  a  normal  (though 
somewhat  distended)  duodenum  drawn  to  the  same  scale  for  comparison.  The  distended  duodenum 
of  this  patient  is  shown  in  situ  in  Fig.  2,  and  an  actual  skiagram  of  the  duodenum  in  Fig.  3.  The 
primary  cause  of  the  duodenojejunal  kinking  is  shown  in  Fig.  4.  The  patient's  main  symptom  was 
pain  in  the  region  of  her  duodenum,  "hke  something  distended  which  would  burst  if  it  were  tapped 
upon  either  in  front  or  behind."  o,  b,  c,  first,  second,  and  third  parts  of  the  duodenum;  Py,  pylorus; 
P,  pyloric  portion  of  stomach;  Jej,  jejunum;  U,  umbilicus;  Cr,  crest  of  ilium. 


suddenly  through  the  duodenojejunal  junction  and  forthwith  began 
to  course  rapidly  through  the  coils  of  the  jejunum.  The  subsequent 
examinations  afforded  a  perfect  illustration  of  the  fact  that  the  duodeno- 
jejunal kinking  is  secondary  to  stasis  at  the  lower  end  of  the  ileum. 
After  a  night's  rest,  fifteen  hours  after  the  bismuth  meal,  the  stomach 


590      \ARl(Ji\S  DLSEASES  AND  THEIR  GASTRIC  RELATIONS 

and  duodenum  no  longer  contained  any  bismuth;  the  greater  part  of 
it  was  found  to  be  in  the  knver  coils  of  the  ileum  in  the  pelvis.  The 
cecum  also  occupied  the  pelvis  and  contained  a  quantity  of  bismuth, 
while  a  small  amount  was  already  present  in  the  ascending  and  trans- 
verse colon.  Twenty-seven  hours  after  the  bismuth  meal  there  was  still 
some  bismuth  in  the  lower  end  of  the  ileum,  and  the  most  advanced 
portion  had  reached  the  sigmoid,  thus  the  sojourn  of  the  bismuth  in 
the  small  intestine  was  more  than  three  times  the  normal." 

Diagnosis. — The  diagnosis  is  suggested  by  the  dependence  of  the  pain 
on  the  upright  posture  and  its  relief  by  rest,  as  well  as  by  coexisting 
phenomena  of  intestinal  stasis,  indicated  in  the  history  of  Jordan's 
patient. 

Treatment. — The  treatment,  properly  speaking,  should  be  surgical. 
The  question  of  the  propriety  of  ileosigmoidal  anastomosis  as  advocated 
by  Lane  is  still  .sub  judicc,  with  perhaps  an  increasing  reluctance  on  the 
part  of  conservative  surgeons  lightly  to  undertake  the  task.  It  would 
be  proper,  howe\er,  if  obstructiA'e  duodenal  kinking  appeared  as  a 
constant  feature,  either  to  perform  gastrojejunostomy  with  duodenal 
inclusion,  or  to  straighten  out  the  kink  by  fixing  the  first  portion  of 
the  jejunum  in  position  by  suture.  The  operation  which  seems  to  be 
growing  in  favor,  though  still  sub  judice,  is  exsection  of  the  cecum, 
ascending,  and  a  portion  of  the  transverse  colon. 

Chronic  Arteriomesenteric  Constriction. — The  root  of  the  mesentery 
containing  the  superior  mesenteric  bloodvessels  passes  from  behind 
forward  to  lie  across  the  duodenum,  compressing  it  against  the  verte- 
bral column.  A  normal  pressure  is  always  maintained  at  this  point, 
but  so  slight  as  to  be  easily  overcome  by  duodenal  contractions,  so 
that' no  actual  obstructing  compression  results. 

In  some  instances,  however,  causes  which  produce  mechanically  a 
downward  traction  on  the  root  of  the  mesentery  may  result  in  actual 
duodenal  compression. 

The  relationship  between  arteriomesenteric  constriction  and  gastrop- 
tosis  has  been  considered  under  the  latter  heading. 

Under  "acute  dilatation"  will  be  found  a  full  description  of  the 
relationship  between  this  disease  and  duodenal  constriction  by  a 
taut  mesentery. 

Aside  from  these  cases  there  is  a  clinical  grouj)  characterized  In- 
recurring  attacks  of  pain  and  duodenal  regurgitation,  in  which  arterio- 
mesenteric constriction  can  be  demonstrated  by  surgical  exploration. 

The  patient  usually  gives  a  long  antecedent  history  of  obstinate 
constipation.  After  a  variable  period  of  time  there  occur  attacks 
of  ])aiii,  nausea,  and  xoniitiiig,  tlie  vomited  matters  l)eing  ])r()fuse  and 
coiitaiiiing  bile  aixl  other  constituents  of  duodenal  secretions. 


GASTRIC  CRISIS  OF  TABES  DORS  A  LIS  591 

After  the  attack  has  lasted  a  few  hours  the  symptoms  subside  until, 
after  a  time,  the  complaint  repeats  itself. 

Exploration  in  these  cases  has  shown  a  movable  cecum  dropping 
downward  over  the  brim  of  the  pelvis,  and  dragging  upon  a  mesentery 
that  is  abnormally  short.  Both  factors  seem  to  be  essential,  the 
downward  displaced  cecum  and  the  abnormally  short  mesentery. 

Bloodgood,  of  Baltimore,  has  called  attention  to  these  cases,  and 
proved  the  pathogenical  mechanism  of  the  complaint. 

The  majority  of  the  patients  in  whom  these  conditions  have  been 
found  have  been  treated  surgically  by  exsection  of  the  ascending  and  a 
portion  of  the  transverse  colon,  so  that  fecal  stasis  would  not  drag 
upon  the  shortened  mesentery. 

Duodenal  Regurgitation  Due  to  Excessive  Amount  of  Fats  in  the  Diet. 
— Bassler,  of  New  York,  has  described  a  series  of  cases  giving  the 
same  clinical  history,  which  he  attributes  to  duodenal  regurgitation, 
occasioned  by  an  excessive  diet  of  fats.  According  to  this  writer  the 
pain  may  be  severe  enough  to  incapacitate  the  patient  for  the  time 
being,  coming  suddenly,  often  disappearing  abruptly  but  quite  inde- 
pendent of  the  meals.  The  fasting  stomach  usually  contains  duodenal 
secretions,  bile  fats,  and  fatty  acids,  the  composite  liquids  occasion- 
ally attaining  the  quantity  of  from  50  to  75  c.c.  The  test  breakfast 
is  abundant,  amounting  to  900  c.c.  in  one  of  Bassler's  cases,  is  bile- 
tinged,  and  show^s  a  floating  layer  of  fat  globules.  In  the  filtrate  the 
pancreatic  fermentation  may  be  demonstrated.  Reactions  for  hydro- 
chloric acid  depend  upon  the  degree  of  neutralization  by  the  alkaline 
secretions  of  the  duodenum.  If  the  gastric  contents  be  removed  at 
the  time  of  pain,  reactions  and  appearances  are  observed  similar  to 
those  of  the  test  breakfast.  Recovery  promptly  follows  the  enforce- 
ment of  the  fat-free  diet.  Whether  Bassler's  cases  constitute  a 
clinical  entity  remains  to  be  seen.  The  writer  has  no  experience  in 
such  advanced  cases  as  have  been  described  by  Bassler,  although  he 
has  encountered  instances  of  a  milder  type. 

Differentiation  from  duodenal  kinks  and  arteriomesenteric  constric- 
tion has  not  seemed  to  him  to  be  possible. 


GASTRIC   CRISIS    OF    TABES    DORSALIS 

Ever  since  Delamarre*  in  1866  studied  the  relationship  of , the  gastric 
manifestation  of  tabes  to  the  disease  itself  and  Charcot-  in  ISSl  more 

'  Des  Troubles  Gastriques  dans  I'Ataxie  Locoiuotrice,  These  de  Paris,  1866. 
^  Lemons  sur  les  Maladies  du  Systeme  Nerveux,  Paris,  1800,  t.  ii,  p.  19. 


592      VARIOUS  DISEASES  AND   THEIR  GASTRIC  RELATIONS 

carefully  analyzed  the  clinical  features  of  the  paroxysm,  the  gastric 
crises  of  tabes  have  been  classed  among  the  most  striking  phenomena 
of  clinical  medicine. 

When  they  occur  in  patients  in  whom  the  existence  of  tabes  is  plainly 
demonstrable  they  concern  chiefly  the  neurologist,  but  not  uncommonly 
they  occur  in  those  in  whom  other  evidences  of  tabes  are  utterly  lacking, 
even  after  most  painstaking  examination,  until  several  years  after  the 
beginning  of  the  attacks.  In  such  cases  their  occurrence  is  a  matter 
of  extreflie  importance  to  all  clinicians,  and,  therefore,  they  demand 
attention  when  the  symptoms  of  gastric  disorders  are  being  considered. 

The  frequency  of  this  symptom-complex  is  variously  stated  by  dif- 
ferent authorities.  RoesteP  concludes  that  as  many  as  30  per  cent, 
of  all  cases  of  tabes  show  gastric  crisis  at  some  time  during  the  course 
of  the  disease,  while  others  place  the  figure  as  low  as  10  per  cent,  or  even 
6  per  cent. 

AVlien  a  history  of  luetic  infection  may  be  obtained  it  will  usually 
be  found  that  the  attacks  first  make  their  appearance  on  an  average 
of  six  to  seven  years  after  the  date  of  infection,  although  this  is  by  no 
means  invariable.  Cases  have  been  recorded  in  which  the  crisis 
developed  within  two  or  three  years  after  the  initial  infection.  They 
are  most  frequently  first  observed  in  the  preataxic  stage  of  the  disease 
and  may  occur  several  years  before  changes  in  pupillary  reactions 
and  patellar  reflexes  can  be  detected. 

Symptoms. — One  of  the  most  characteristic  features  of  gastric 
crisis  in  tabes  is  the  suddeiniess  with  which  the  transition  is  made 
from  a  condition  of  apparent  comfort  to  one  of  extreme  agony.  Pro- 
dromas  are  almost  unknown.  The  patient  at  any  time  and  without 
the  slightest  warning  is  suddenly  seized  with  violent  paroxysms  of 
abdominal  pain,  usually  beginning  in  the  lower  abdomen  or  groin  and 
radiating  to  the  epigastrium,  in  which  it  may  remain  fixed  throughout 
the  attack.  Sometimes  the  patient  feels  as  though  painful  constriction 
was  being  made  about  the  waist.  The  pain  radiates  to  the  precordium, 
sometimes  to  the  intrascapular  region,  and  less  frequently  doAvn  the 
arms. 

The  onset  of  the  pain  is  accompanied  or  soon  followed  by  vomiting, 
first  of  stomach  contents  and  then  of  clear  liquid,  containing  mucus, 
bile,  or  even  blood.  The  vomiting  and  retching  seem  to  become  more 
violent  after  the  stomach  contents  are  expelled  and  are  often  uncon- 
trollable. Vomiting  may  be  preceded  by  choking  sensations  and  loud 
eructations  of  gas  and  hiccoughs.     Throughout  the  attack  gas  may 

'  Beitrage  zur  Patliolofiic  nnfl  I'hrrapy,  hoi  Crinos  CJastrique  boi  Tabes  Dorsalis, 
Inaiip;.  Dissert.,  lierlin,   ISO.'i. 


GASTRIC  CRISIS  OF  TABES  DORS  A  LIS  593 

be  expelled  from  the  bowel  and  exceptionally  there  may  be  abdominal 
distention.  Constipation  is  the  rule,  but  diarrhea  when  present  is 
severe  and  often  very  exhausting. 

In  severe  attacks  of  considerable  duration  the  condition  of  the  patient 
becomes  distressing.  The  pain  is  most  agonizing  and  terrifying  and  the 
patient  thrashes  about  the  bed  and  assumes  most  unusual  attitudes 
in  his  efforts  to  find  relief.  As  the  loss  of  so  much  fluid  by  vomiting 
continues  with  the  impossibility  of  retaining  anything  in  the  stomach, 
emaciation  is  rapid.  The  skin  is  pale,  cold,  and  clammy,  the  pulse 
rapid,  growing  weaker  as  the  attack  continues.  The  temperature  is 
almost  always  normal  or  subnormal.  The  abdomen  is  usually  flat  and 
retracted  and  tender  everywhere,  but  most  of  all  in  the  epigastrium. 
Succussion  sounds  are  absent.  Areas  of  cutaneous  hyperesthesia  and 
anesthesia  may  often  be  found. 

The  duration  of  a  single  attack  varies  from  ten  or  twelve  hours  to 
two  weeks  or  even  longer,  the  average  being  from  five  to  seven  days. 
Most  striking  is  the  abruptness  with  which  the  majority"  of  cases  ter- 
minate. Not  only  does  the  pain  completely  disappear,  but  in  cases  of 
moderate  duration  a  patient  who  a  few  hours  before  was  suffering 
violent  pain  and  vomiting  incessantly,  calls  for  food  which  he  eats 
with  relish  and  seems  perfectly  able  to  digest.  When  the  attack  has 
persisted  for  several  days  cessation  of  the  pain  is  often  followed  by  a 
long  sleep,  after  which  the  digestive  functions  seem  perfectly  restored. 

In  not  all  cases,  however,  are  the  attacks  followed  by  so  prompt  a 
recovery.  In  many  the  return  to  health  is  gradual,  and  there  may  be 
a  longer  or  a  shorter  period  of  impairment  of  the  digestive  powers. 
Exceptionally  the  attacks  may  terminate  fatally  from  cardiac  exhaus- 
tion or  from  long-continued  and  profuse  diarrhea. 

The  extreme  variations  in  the  gastric  crises  is  exhibited  in  the  same 
individuals  in  different  attacks  as  well  as  in  different  individuals.  The 
most  constant  features  are  the  sudden  onset,  abrupt  termination,  pain, 
and  vomiting.  Very  rarely  is  vomiting  absent  and  almost  as  rare  are 
those  attacks  in  which  there  is  vomiting  without  pain  but  with  the  other 
manifestations  of  the  disorder.  In  duration  and  the  relative  promi- 
nence of  different  groups  of  s,ymptoms  a  single  attack  will  present  the 
widest  departure  from  the  average.  It  is,  therefore,  impossible  to 
make  any  clinical  classification  of  the  different  tj^pes  of  gastric  crises, 
and  equally  impossible  in  a  given  case  to  make  any  prognosis  as  to 
the  duration  and  frequency  of  the  attacks. 

Variability  is  a  characteristic  also  of  the  course  followed  by  the 

crises.    In  some  cases  attacks  of  two  or  three  days'  duration  may  return 

with  a  semblance  of  regularity  every  month  or  six  weeks,  or  they  may 

recur  in  this  manner  for  several  years  and  then  may  become  entirely 

38 


594      VARIOUS  DISEASES  AND  THEIR  GASTRIC  RELATIONS 

irregular.  Irregularity  is  far  more  common  in  the  duration  of  different 
attacks  in  the  same  individual.  Sometimes  an  interval  of  several 
years  frequently  may  be  enjoyed.  In  a  few  cases  the  attacks  have  been 
known  to  disappear  permanently  after  two  or  three  paroxysms.  This, 
however,  is  rare.  It  is  much  more  common  for  them  to  increase  in 
frequency  and  severity  as  the  spinal  disease  progresses. 

Diagnosis.— Gastric  Analysis. — Von  Noorden^  concluded  after  a  series 
of  examinations  of  the  gastric  contents  of  tabetic  patients  made  before, 
during,  and  after  the  crises,  that  no  characteristic  changes  took  place 
in  the  gastric  secretion.  He  found  very  variable  degrees  of  acidity 
which  bore  no  apparent  relation  to  the  paroxysm. 

The  work  of  observers  in  more  recent  years  tends  to  support  this 
view.  Friedenwald  and  Leitz^  after  studying  the  gastric  contents  of  the 
series  of  42  cases  of  tabes  in  which  gastric  crises  occurred,  all  males 
between  the  ages  of  twenty-nine  and  sixty-four,  found  the  results 
as  follows : 

In  35  patients  from  whom  the  gastric  contents  were  obtained  during 
crises  6  showed  local  acidity,  13  showed  hyperacidity,  10  showed  hypo- 
acidity, 6  showed  variable  acidity.  In  36  patients  from  whom  the 
gastric  contents  were  obtained  between  the  crises,  14  showed  normal 
acidity,  12  showed  hyperacidity,  10  showed  hypoacidity.  Of  the 
entire  series— 42  patients — only  4  showed  hypersecretion. 

Treatment. — During  the  attack  the  chief  indication  of  treatment  is 
to  relieve  the  patient  as  far  as  possible  of  his  pain  and  distress,  and  some 
form  of  sedative  or  narcotic  treatment  is  almost  always  necessary. 
The  simplest  and  least  objectionable  drugs  should  at  first  be  tried. 
The  writer  has  found  as  much  relief  by  the  combined  use  of  veronal 
and  trional  in  small  repeated  doses  as  from  any  one  of  the  other  forms 
of  treatment.  These  drugs  are  best  given  in  combination,  in  doses 
of  2^  grains  each,  repeated  every  two  to  four  hours.  A  calmative 
effect  is  observed  almost  from  the  start  and  a  prolonged  and  restful 
sleep  is  produced  when  the  paroxysm  ceases.  Antipyrine  in  15-grain 
doses  may  be  given  every  four  to  six  hours,  preferably  by  rectum, 
but  it  should  be  discontinued  if  depressant  symptoms  occur.  Cerium 
oxalate  in  5-grain  doses  every  few  hours  is  of  good  report,  but  has 
proved  invariably  disappointing  in  the  writer's  experience.  If  the  par- 
oxysm be  not  controlled  by  the  foregoing  medication  it  may  be  necessary 
to  resort  to  codeia,  morphine,  or  hyoscin.  Codeia  should  first  be  used 
as  the  most  free  from  objection;  morphine  should  be  withheld  as  long 
as  possible.     Extreme  care  must  be  employed  in  the  use  of  these 

'  Pathologie  der  Gastrischen  Crisen  Charite  Annalen,  1890. 
^  Maryland  Medical  Journal,  July,  1912. 


VISCERAL  CRISES  IN  ERYTHEMAS  595 

narcotics,  as  the  pain  may  create  a  temporary  tolerance  which  ceases 
when  the  paroxysm  suddenly  subsides,,  leaving  the  patient  unpleasantly 
under  the  effects  of  the  narcotic.  Hj^oscin  must  be  given  with  extreme 
caution,  as  the  writer  has  seen  alarming  symptoms  from  doses  generally 
considered  to  be  safe.  It  is  advisable,  therefore,  not  to  give  the  drug 
in  larger  doses  than  grain  yttt.  which,  however,  may  be  repeated  at 
such  intervals  as  may  be  necessary. 

The  epidural  injections  of  cocaine  have  been  recommended  by  Ewald. 
The  writer  has  no  experience  with  this  form  of  treatment.  Counter- 
irritation  to  the  epigastrium  and  cupping  of  the  spine  may  apparently 
relieve  for  the  time  being. 

There  are  no  specific  rules  for  diet.  Food  may  be  given  in  any  form 
or  in  any  w^ay  that  seems  advisable.  There  is  no  reason  for  starving 
the  patient,  nor  does  food  produce  an  increase  in  the  distress.  After 
the  attack  is  over  the  Wassermann  test  should  be  made,  and  if  positive, 
active  antisyphilitic  treatment  should  be  employed,  especially  b}^  the 
intravenous  injections  of  salvarsan. 

Forster  of  Breslau  is  an  advocate  of  resection  of  the  posterior  nerve 
roots  in  severe  recurring  crises  and  has  reported^  that  of  25  cases  under- 
going such  an  operation  23  recovered,  2  died.  Of  the  23  surviving 
patients  the  results  were  as  follows: 

No  relapse '  ...      13  cases 

Relapse 7  cases 

No  result 2  cases 

These  statistics  are  quite  encouraging,  especially  as  improvements 
in  technique  may  be  followed  by  even  more  brilliant  results. 


VISCERAL   CRISES   IN   ERYTHEMAS 

There  is  a  very  important  group  of  cases,  in  which,  to  the  obvious 
cutaneous  manifestations  of  the  erythemas,  including  purpura, 
urticaria,  and  angioneurotic  edema,  there  are  added  various  visceral 
manifestations,  most  commonly  colic,  with  nausea  and  vomiting  and 
diarrhea,  and  often  hemorrhages  from  the  mucous  membranes.  The 
pathology  of  these  conditions  is  little  understood,  but  it  is  presumed 
that  the  visceral  symptoms  are  the  result  of  changes  in  corresponding 
organs,  dependent  on  the  instability  of  the  vasomotor  mechanism. 
This  underlying  condition  has  been  termed  "vasomotor  ataxia"  by 
S.  Solis  Cohen.^ 

'  Lancet,  July  8,  1911. 

-  Amer.  .Jour.  Med.  Sci.,  February,  1894,  cvii,  145. 


596      VARIOUS  DISEASES  AND   THEIR  GASTRIC  RELATIONS 

The  classification  of  the  cases  which  make  up  this  most  remarkable 
group,  according  to  the  type  of  skin  lesion  present  in  each  case,  is 
extremely,  difficult,  because  of  the  wide  variety  and  difference  in  the 
cutaneous  manifestations.  Not  only  may  these  be  strikingly  different 
in  cases  presenting  very  similar  visual  symptoms,  but  also  in  the  same 
individual  they  may  assume  a  different  form  in  the  different  attacks. 
They  are,  however,  essentially  due  to  vascular  changes. 

Osier, ^  to  whom  we  are  very  largely  indebted  for  bringing  this  group 
of  eases  to  the  notice  they  deserve,  classes  them  as  follows: 

1.  Cases  of  pure  angioneurotic  edema. 

2.  Cases  in  which  the  associated  skin  lesions  is  urticaria. 

3.  Cases  of  Henoch's  purpura,  with  arthritis,  erythema  or  purpura, 
and  colic. 

4.  Cases  with  erythema  multiforme,  with  or  without  edema,  and  most 
frequently  with  more  or  less  redness  or  purpura. 

5.  Cases  showing  recurring  colic,  and  nothing  else,  often  for  years 
before  the  appearance  of  any  skin  lesion. 

S.  Solis  Cohen^  considers  Henoch's  purpura  apart  from  the  others, 
calling  attention  to  its  severity  and  ''probable  dependence  on  definite 
toxins,  if  not  on  specific  infections."  He  states,  however,  that  there  is 
probably  some  fundamental  relationship  between  them. 

In  observations  of  the  actual  gross  changes  found  in  the  organs, 
we  are  indebted  to  those  surgeons  who  have  operated  upon  patients 
during  a  visceral  crisis.  The  operative  findings  at  these  times  vary 
somewhat.  Most  of  the  cases  show  a  small  amount  of  free  fluid  (100 
to  200  c.c.)  in  the  peritoneal  cavity,  which  may  be  clear,  turbid,  or  dis- 
tinctly bloody.  The  intestinal  wall  may,  for  the  space  of  several  inches, 
be  extremely  swollen  and  edematous,  and  perhaps  dark  red;  tlie  last 
portion  of  the  ileum  seems  to  be  a  favorite  site  for  such  a  swelling. 
The  intestinal  peritoneum  is  usually  congested,  and  may  be  studded 
throughout  with  petechia?  and  larger  ecchymotic  areas.  One  operator' 
reported  that  most  of  the  intestine  was  pale  and  in  spasmodic  con- 
traction. It  is  usually  found  collapsed.  Either  petechiae  and  ecchy- 
moses  or  the  swelling  of  the  intestinal  wall  may  be  entirely  absent. 
If  the  case  is  operated  on  during  the  interval  l)ctween  attacks — some- 
times because  the  gall-bladder  has  been  thought  to  be  the  cause  of  tlic 
trou})l(' — the  a})dominal  organs  may  appear  quite  normal. 

Etiology. — Members  of  certain  families  are  predisposed  to  this  con- 
dition, as  might  be  expected,  for  heredity  has  a  notable  influence  on  the 

'  Johns  Hojjkins  Hosp.  Bull.,  vol.  xv,  p.  200. 
-  New  York  Med.  Jour.,  1910,  vol.  xci,  p.  366. 
'  n.  M.  Silvor,  Amor.  Jour.  Rurp;.,  May    1009. 


VISCERAL  CRISES  IN   ERYTHEMAS  597 

erythemas.  P^nsor'  cites  a  family  of  eighty  of  whom  thirty-three  had 
been  afi'ected  with  angioneurotic  edema,  and  in  the  well-known  case 
mentioned  by  Osier  this  disease  was  traced  through  five  successive 
generations  of  the  same  family. 

As  the  disorder  is  prone  to  recurrences  throughout  life,  the  previous 
history  of  the  patient  may  show  that  he  has  suffered  repeatedly  from 
distur})ances  which  are  common  evidences  of  vasomotor  instability 
as  transient  skin  eruptions  with  or  without  vague  attacks  of  arthritis, 
asthma,  hay  fever,  or  repeated  unexplained  hemorrhages;  also  from 
hysteria,  hyperidrosis,  drug  idiosyncrasies,  vertigo,  migraine,  pseudo- 
angina,  transient  hemiopia,  and  other  visual  disturbances,  and  inter- 
mittent polyuria.  It  is  not  uncommonly  present  in  sufferers  from  pul- 
monary tuberculosis,  angina  pectoris,  valvular  heart  disease,  chorea, 
and  epilepsy.  Raynaud's  disease  in  some  of  its  forms  may  be  con- 
sidered an  associated  condition  in  which  the  vasomotor  disturbance  is 
manifested  by  local  constriction  rather  than  by  dilatation. 

A  host  of  influences,  many  of  them  seemingly  trivial,  may  serve  as 
the  exciting  cause  of  an  attack;  among  these  are  reflex  excitation  of 
any  kind,  cold,  emotion,  and  toxins  formed  in  the  body,  especially  in 
the  gastro-intestinal  tract;  for  example,  strawberries  or  shell-fish,  which 
act  as  poisons  when  eaten  by  certain  individuals. 

Symptoms. — The  type  of  patient  in  whom  these  conditions  are 
found  is  an  important  part  of  the  picture.  There  are  usually  the  evi- 
dences of  marked  instability  of  the  vasomotor  system:  dermographia, 
peculiar  mottlings  of  the  skin,  rapidity  and  extreme  variability  in  rate 
of  the  heart  action,  which  is  easily  disturbed;  or  irregularity,  palpita- 
tion, or  intermittent  tachycardia.  Functional  murmurs  may  be  found. 
Besides  this  there  have  been  described  in  many  cases  a  widening  of 
the  commissure  of  the  eyelids,  tremulousness  of  the  lids  on  light  closure, 
dilatation  of  the  pupils,  which  react  but  show  wide  oscillation. 

During  an  attack  the  character  of  the  skin  eruption  may  be  variable 
in  the  extreme.  There  may  be  purpura  of  various  degrees — sometimes 
resembling  measles  or  erythema,  w4th  urticaria,  or  nodules  with  a 
dark  centre.  The  only  feature  in  any  way  approaching  constancy 
is  the  distribution,  which  is  most  often  over  the  extensor  surfaces  of 
hips,  knees,  ankles,  and  elbows.  Exceptionally  the  only  discoverable 
area  of  eruption  may  have  other  less  expected  locations.  There  may 
be  only  limited  evidences  of  angioneurotic  edema,  and  in  the  difficult 
cases  embraced  in  class  five  of  Osier's  classification  no  skin  lesion  may 
be  visible. 

Recurring  attacks  of  colic  are  a  far  more  constant  feature  than  are 

'  Guy's  Hospital  Reports,  vol.  Iviii,  p.  111. 


59S      VARIOUS  DISEASES  AND   THEIR  GASTRIC  RELATIONS 

many  of  the  cutaneous  manifestations.  These  come  on  at  variable 
intervals  of  a  month  or  more,  sometimes  permanently  disappearing, 
but  usually  exhibiting  a  marked  tendency  to  persistent  recurrence. 
The  onset  may  be  accompanied  by  a  chill.  The  pain  is  violent,  often 
beginning  in  the  epigastrium  and  becoming  diffuse  over  the  entire 
abdomen;  in  the  other  cases  it  may  be  confined  to  the  lower  half  of 
the  abdomen,  or  it  may  be  very  indefinite  in  location.  Radiation  is  not 
common,  but  cases  have  been  known  to  very  closely  simulate  biliary 
or  renal  colic.  Xausea,  vomiting  of  stomach  contents,  clear,  greenish, 
or  bloody  fluid,  and  diarrhea  with  the  passage  of  blood,  sometimes 
following  constipation,  are  fairly  constant  accompaniments  of  the  colic. 

During  an  attack  of  colic  the  patient  usually  appears  extremely 
ill.  The  abdomen  presents  no  constant  signs,  but  often  there  is  general 
rigidity  and  tenderness  over  the  colon,  appendix,  or  epigastrium,  or 
in  all  of  these  locations.  Distention  is  rare,  the  abdomen  often  being 
decidedly  retracted.  In  some  cases  a  mass  has  been  distinctly  felt, 
which  subsequent  operation  has  shown  to  be  the  swollen  portion  of 
intestine  as  above  described.  The  spleen  is  moderately  enlarged  in  a 
fair  proportion  of  the  cases.  A  moderate  rise  of  temperature  up  to 
101°  is  common.  The  blood  usually  shows  no  changes  in  coagula- 
tion time,  a  moderate  leukocytosis — up  to  14,000  (although  two  cases, 
showing  over  30,000,  have  been  reported) — and  a  normal  dift'erential 
count.  Among  the  less  common  but  important  features  of  the  attacks 
are  albuminuria,  with  casts  and  blood,  hemorrhages  into  any  mucous 
membrane  or  retina,  and  arthritis. 

A  very  severe  form  of  acute  nephritis  is  a  most  important  if  not  the 
most  common  complication.  It  is  not  infrequently  the  cause  of  a  fatal 
termination,  and  may  first  make  its  appearance  when  the  skin  manifes- 
tations are  at  their  height,  or  not  until  several  days  or  even  weeks 
after  their  disappearance.  Osler^  draws  attention  to  the  fact  that  in 
the  most  intense  form  of  the  nephritis  there  may  be  no  edema.  In  his 
series  he  has  never  met  with  nephritis  as  a  complication  in  a  case  of 
pure  angioneurotic  edema.  Endocarditis,  i)ericarditis,  pleurisy,  and 
pneumonia  are  rare  complications. 

Intussusception  complicated  a  case  reported  by  Sutherland.'-  Its 
importance  lies  in  the  similarity  of  the  symptoms  of  an  attack  with 
colic  to  those  of  intussusception.  Peritonitis  resulting  from  a  perfora- 
tion of  the  fundus  of  the  stomach  is  reported  by  Silbermann^  in  a  case 
which  showed  necrotic  foci  in  stomach  and  intestinal  walls,  but  without 

'  Amer.  Jour.  Med.  Sci.,  1904,  cxxvii,  19. 

«  British  Jour.  Child.  Dis.,  1904,  i,  26. 

»  Pediatrische  Arbcitcn,  Festschrift  Herri  Edward  Henoch,  1S90,  p.  239. 


VISCERAL  CRISES  IN  ERYTHEMAS  599 

ulceration.  There  had  been  recurrent  attacks  of  fever,  pains  in  the 
knees,  purpura,  coHc,  and  melena. 

While  the  gastro-intestinal  crises  are  the  most  frequent  of  the  visceral 
manifestations,  nevertheless  crises  apparently  resulting  from  disturb- 
ances in  other  organs  often  occur.  Such  are  aphasias,  hemiplegias, 
monoplegias,  swelling  of  the  fauces  and  pharynx,  edema  of  the  glottis, 
and  asthma,  which  seems  to  be  especially  frequent  with  urticaria. 
The  causative  structural  changes  are  thought  to  resemble  those  found 
in  the  abdominal  organs. 

Diagnosis. — It  must  not  be  forgotten  that  certain  forms  of  the 
so-called  exudative  erythema  are  frequently  secondary  to  organic 
disease,  such  as  chronic  valvular  cardiac  disease,  hepatic  cirrhosis, 
cholelithiasis,  and  nephritis.  An  important  step  in  diagnosis  therefore 
is  the  exclusion  of  these  organic  lesions. 

The  type  of  patient  in  whom  the  attacks  occur,  shown  both  by  a 
careful  history  and  physical  examination,  has  no  small  influence  in 
deciding  the  question  of  the  nature  of  the  attack.  Attempts  to  differ- 
entiate the  attacks  from  colic  with  abdominal  inflammatory  conditions, 
by  means  of  the  symptoms  and  physical  signs  alone,  are  attended  with 
much  difficulty  on  account  of  the  diversity  with  which  the  symptoms 
of  the  former  are  grouped.  It  is  always  to  be  borne  in  mind  that  the 
two  conditions  may  coexist. 

In  acute  appendicitis  the  vomiting  at  the  onset,  if  present,  is  more 
likely  to  be  of  stomach  contents  only  and  of  shorter  duration,  and 
bloody  stools  are  much  more  rare  than  is  the  case  with  the  visceral 
crises.  Tenderness  is  usually  more  marked  and  more  definitely 
localized,  and  rigidity  is  much  more  constant. 

Intussusception  is  extremely  hard  to  differentiate,  especially  in  the 
absence  of  a  cutaneous  eruption.  A  careful  inquiry  for  a  history  of 
previous  attacks  of  erythema,  and  a  searching  examination  for  the 
minutest  evidence  of  the  present  existence  thereof,  in  all  cases  pre- 
senting paroxysmal  abdominal  symptoms,  will  greatly  aid  in  avoiding 
errors. 

Treatment. — At  present  we  know  of  no  means  of  preventing  a 
recurrence  of  the  attacks  in  these  cases.  Camphor  and  arsenic  both 
have  their  advocates,  but  more  extended  trial  is  necessary  before  their 
use  is  attended  with  any  certainty  of  success. 

The  question  of  surgical  intervention  is  an  important  one.  While 
we  cannot  agree  with  the  view  of  some  surgeons  that  most  cases  showing 
the  symptom-complex  under  discussion  are  benefited  by  operation, 
still  serious  inflammatory  conditions  coexist  in  a  sufficient  number 
of  cases  to  make  operation  by  far  the  lesser  danger  in  cases  of  great 
doubt. 


000      VARIOUS  DISEASES  AND   THEIR  GASTRIC  RELATIONS 

Osier  emphasizes  the  importance  of  rest  in  bed  and  a  milk  diet 
for  a  sufficient  length  of  time  to  guard  against  the  development 
or  progress  of  the  nephritis. 


EPIGASTRIC    HERNIA 

Epigastric  hernia  may  occur  in  two  forms.  The  first  or  true  hernia 
occurs  whenever,  through  a  cleft  in  the  abdominal  wall  a  peritoneal 
sac  is  projected,  containing  usually  omentum,  occasionally  portions  of 
the  small  intestine,  or  exen  of  the  wall  of  the  stomach  itself.  This  form 
of  hernia  is  well  known  and  needs  no  further  description. 

A  second  form  of  hernia,  often  unrecognized,  is  frequently  the  cause 
for  prolonged  dyspepsia,  and  the  description  is  limited  to  this  variety. 

Epigastric  hernia,  known  also  as  preperitoneal  lipoma,  consists  in 
the  intrusion  of  a  small  mass  of  preperitoneal  fat  through  a  minute 
cleft  or  deficiency  in  the  aponeurosis  of  the  abdominal  wall.  The  mass 
varies  in  size  from  the  head  of  a  pin  to  a  small  chestnut,  and  is  composed 
almost  entirely  of  subperitoneal  tissues,  although  it  is  possible  that  a 
cone-like  projection  of  the  peritoneum  itself  may  be  drawn  into  the 
orifice. 

The  ordinary  situation  for  the  hernia  is  in  the  median  line  between 
the  umbilicus  and  the  xiphoid.  So  commonly  are  they  found  in  this 
situation  that  the  term  "hernia  of  the  linea  alba"  is  often  employed  to 
designate  them.  A  not  infreciuent  situation  is  the  upper  portion  of  a 
patulous  umbilical  ring,  which  rounded  at  its  lower  circumference  ter- 
minates in  the  upper  portion  in  a  narrow  slit,  the  outline  resembling 
a  pear,  the  lineal  cleft  representing  the  short  stem.  Less  frequently 
hernia  appears  at  the  outer  edge  of  either  rectus  or  engages  in  clefts 
in  the  inner  layer  of  the  sheath  of  the  rectus  muscle.  The  hernia  may  be 
single  or  multiple,  rarely,  however,  exceeding  three  or  four  in  number. 
The  disorder  is  far  more  common  in  men  than  in  women. 

Etiology. — The  exact  mode  of  origin  of  the  hernia  is  unknown.  The 
cleft  may  rei)resent  congenital  deficiency  or  may  possibly  result  from 
minor  traumatism,  although  the  clinical  history  rarely  gives  any  inti- 
mation of  previous  injury.  The  history  of  a  rapid  loss  of  weight  pre- 
ceding the  hernial  symptoms  is  so  commonly  elicited  that  it  would 
seem  as  though  disappearance  of  fibrous  fat  has  allowed  the  entrance 
of  the  herniated  tissues  through  a  cleft  thus  previously  occluded.  It  is 
certain  that  little  masses  of  sul^peritoneal  fat  may  penetrate  the  spaces 
formed  by  the  fibers  of  the  linea  alba,  especially  around  the  course  of 
the  small  vessels  and  nerves  which  pass  through  these  spaces.  If  this 
little  mass  continues  to  grow,  the  ojjening  through  which  it  passes 


EPIGASTRIC  HERNIA 


GOl 


is  stretched  about  the  pedicle  of  the  hernia  so  that  it  exerts  a  pressure 
upon  it  whenever  the  abdominal  wall  is  rendered  tense  by  muscular 
effort.  To  the  base  of  the  pedicle  the  omentum  may  become  adherent. 
Symptoms. — The  chief  symptom  is  pain  localized  in  the  epigastrium, 
occasionally  showing  irregular  radiations.  It  may  })e  described  as  sharp 
or  lancinating,  although  it  is  usually  of  a  dull  aching  character.  Although 
the  point  of  tenderness  is  extremely  minute,  the  pain  may  be  difficult 
to  locate  accurately  or  may  spread  over  quite  an  extensive  area  of  the 
abdomen.  Exacerbations  in  severity  are  regularly  induced  or  intensified 
by  walking  or  any  physical  exertion  that  demands  the  free  use  of  the 
abdominal  muscles.  The  patient  may  be  quite  comfortable  on  waking, 
but  as  the  day  progresses  the  pain  becomes  more  and  more  nagging 
and  persistent,  gradually  waning  when  the  patient  rests.  Relief  by 
rest  is  not,  however,  as  instantaneous  as  in  angina  abdominalis.    The 


Fig.   126 


Pain  chart  of  a  patient  with  a  small  epigastric  hernia.  On  the  first  clay  the  patient  did  not  rest 
and  the  pain  increased  until  she  laid  down  at  night.  On  the  second  day  relief  came  by  lying  down  in 
the  afternoon. 


pain  may  be  often  intensified  after  eating  during  the  period  of  maximum 
peristalsis.  The  connection  between  the  motor  activity  of  the  stomach 
and  the  localized  hernial  pain  is  not  readily  to  be  explained,  especially 
as  internal  adhesions  do  not  necessarily  constitute  a  part  of  the  morbid 
process. 

Vomiting  is  neither  infrequent  nor  especiall}'  characteristic.  Diarrhea 
has  been  noted  in  several  instances,  the  bowels  assuming  their  normal 
function  when  the  hernia  has  been  rectified.  Irregular  attacks  of 
flatulence  have  also  been  relieved  after  the  hernia  has  been  removed. 

Physical  Examination. — The  characteristic  evidence  of  the  hernia  is 
the  presence  of  a  small  spot  of  exquisite  tenderness  in  any  of  the  above- 
mentioned  regions  in  which  hernia  commonly  occurs.  The  area  of 
tenderness  is  usually  no  larger  than  the  blunt  end  of  a  pencil  and  the 
line  of  demarcation  is  quite  distinct.     The  sensitiveness  is  intensified 


602      VARIOUS  DISEASES  AND   THEIR  GASTRIC  RELATIONS 

whenexer  the  abdominal  wall  is  put  on  the  stretch,  as  in  attempts  to  rise 
from  a  recumbent  to  a  sitting  position.  If  the  patient  has  been  quiet 
for  several  days  the  tenderness  may  disappear,  so  that  the  most  favor- 
able time  for  examination  is  when  the  patient  is  suffering  from  pain 
after  exercise. 

The  hernia  may  or  may  not  be  palpable.  Small  intrusions  of  fat  may 
be  so  minute  as  to  totally  elude  detection.  In  other  cases  an  extremely 
tender  nodule  the  size  of  a  small  pea,  or  rarely  somewhat  larger,  may 
be  distinctly  felt.  The  size  of  the  hernia  bears  no  relation  to  the  distress 
which  it  produces.  Hernias  of  the  size  of  a  chestnut  or  walnut  may  be 
of  this  type  of  preperitoneal  lipoma,  although  when  they  attain  this 
size  a  true  hernia  with  a  peritoneal  sac  is  to  be  suspected. 

Treatment. — The  treatment  is  entirely  surgical.  A  small  incision 
is  to  be  made  and  the  subcutaneous  fat  in  the  neighborhood  of  the  pain- 
ful spot  removed  down  to  the  aponeurosis.  If  the  hernial  fat  be  de- 
tected it  may  be  tied  off  and  the  opening  closed,  care  being  taken  to 
avoid  opening  the  apex  of  any  possible  peritoneal  protrusion.  In  many 
instances  the  hernia  cannot  be  found,  but  a  clean  dissection  down  to 
the  aponeurosis  and  the  removal  of  all  subcutaneous  fat  that  immediately 
overlies  the  painful  spot  will  result  in  complete  and  uneventful  recovery. 


CHRONIC   LEAD    POISONING 

Lead  is  a  slowly  cumulative  poison.  It  makes  its  entrance  into  the 
body  chiefly  through  the  alimentary  tract,  either  in  water,  or  on  food 
among  those  of  unclean  habits,  or  as  dust  which,  having  entered  the 
upper  respiratory  tract,  is  swallowed  with  saliva.  Whether  or  not  it 
may  enter  the  system  directly  through  the  respiratory  tract  has  been 
much  discussed,  and  can  as  yet  scarcely  be  considered  proved.  It  is 
probable  that  skin  absorption,  if  possible,  is  not  great. 

Thus  are  thousands  of  men  and  women  who  are  daily  exposed  to 
lead  poisoning  on  account  of  their  work.  The  variety  and  number  of 
such  occupations  are  too  great  for  enumeration  here.  It  must  not  be 
overlooked,  however,  that  lead  is  used  in  the  manufacture  of  dry  electric 
batteries  and  many  kinds  of  rubber  goods,  for  at  first  thought  these 
occupations  might  seem  remote  from  the  lead  industry.  Their  impor- 
tance in  increasing  because  they  are  becoming  more  and  more  extensive. 

A  complete  history,  including  occupation,  is  usually  sufficient  to  put 
the  careful  examiner  on  his  guard,  but  even  in  our  i)resent  state  of  civili- 
zation there  are  many  other  ways  in  which  lead  i)()isoning  may  occur. 
Drinking  water  may  become  impregnated  with  a  soluble  salt  of  lead; 
cosmetics,  hair  dyes,  and  cheaper  grades  of  thread  and  dyes  for  dry 


CHRONIC   LEAD   rOISONING  003 

goods  may  be  the  source  of  the  poison.  Fortuiuitely,  there  is  Httle 
chance  tocUiy  of  dan<^er  on  this  account  from  canned  foods.  Unusual 
susceptibiHty  to  its  action  exists  in  certain  individuals  and  families, 
in  those  who  are  regular  users  of  alcohol,  and  especially  in  those  who 
have  sutt'ered  previous  attacks. 

In  the  stomach,  lead  is  probably  converted  into  the  soluble  lead  chlo- 
ride and  absorbed  as  such,  but  in  what  form  it  circulates  in  the  body 
we  do  not  know.  In  fatal  cases  lead  is  found  in  many  of  the  organs 
and  tissues,  but  the  lesions  produced  are  far  less  characteristic  than  are 
the  resulting  symptoms.  The  discrepancy  is  so  marked  that  the  ques- 
tion of  how  the  poison  acts  on  the  tissues  in  producing  symptoms  is 
even  now  unsettled.  Excretion  takes  place  chiefly  through  the  kidneys, 
bile  (lead  is  consequently  found  in  the  feces),  and  to  a  less  extent  in 
sweat,  milk,  and  saliva. 

Symptoms. — Chronic  lead  poison  is  usually  first  shown  by  a  group 
of  general  symptoms  more  or  less  indefinite,  and  which  are  followed 
after  a  period  of  weeks  or  months  by  the  more  characteristic  symptoms, 
colic,  neuritis,  and  severe  cerebral  disturbances.  The  first  symptoms 
are  increasing  loss  of  weight,  loss  of  appetite,  especially  for  breakfast,  a 
sweetish  taste  in  the  mouth,  constipation,  sometimes  alternating  with 
diarrhea,  attacks  of  nausea  and  ^'omiting,  frontal  headache,  attacks 
of  weakness  and  trembling,  spots  before  the  eyes,  pains  in  joints  and 
muscles,  and  a  moderate  anemia  with  disproportionate  pallor. 

The  most  definite  and  characteristic  symptoms  at  this  stage  are  the 
blue  line  or  "lead  line"  on  the  gums  and  the  granular  basophilia  of  the 
red  cells.  They  are  usually  present  at  all  stages  of  the  poisoning  and 
often  when  there  are  no  active  symptoms. 

The  blue  line  is  an  irregular  line  of  purplish  discoloration,  very  close 
to  and  parallel  with  the  edge  of  the  gum,  being  especially  marked  about 
the  lower  incisors  and  canines.  It  occurs  on  both  the  inside  and  outside 
of  the  gum.  When  examined  carefully  or  with  a  lens  it  will  be  seen  to 
be  made  up  of  small  round  dots,  situated  just  beneath  the  surface. 
These  are  deposits  of  lead  sulphide  produced  by  the  action  of  sulphuretted 
hydrogen  liberated  from  the  decomposition  around  the  roots  of  the 
teeth  on  the  lead  circulating  in  the  gum  tissue.  Therefore,  it  is  least 
marked  in  those  whose  teeth  are  kept  cleanest,  and  may  be  absent  when 
there  are  no  teeth  and  the  gums  are  atrophied.  It  persists  for  months 
after  all  symptoms  have  disappeared. 

The  blood  shows  anemia  of  various  grades,  the  red  cells  being 
diminished  out  of  proportion  to  the  diminution  of  hemoglobin,  but 
red  cell  counts  below  two  million  are  rare.  Normoblasts  are  found,  but 
seldom  in  large  numbers.  The  white  cells  show  nothing  characteristic. 
(Iranular  basophilia  of  the  red  cells  is  practically  always  present.    The 


1)04      VARIOUS  DISEASES  AND   THEIR  GASTRIC  RELATIONS 

granules  take  basic  stains,  and  are  usually  small  in  size,  appearing  like 
fine  points.  Often,  howe\'er,  the  size  varies,  some  being  as  large  as 
eosinophile  granules.  Granular  basophilia  is  found  in  other  diseases, 
but  in  none  of  them  is  it  so  evidently  out  of  proportion  to  the  degree 
of  anemia,  and  in  this  lies  a  diagnostic  sign  of  the  greatest  value. 

At  any  time  one  of  the  more  characteristic  symptoms  may  appear, 
colic  being  more  often  the  first.  It  is  apparently  due  to  spasm  of  the 
bowel,  and  is  usually  preceded  by  obstinate  constipation,  and  often 
by  premonitory  pain  of  less  severity.  Sooner  or  later,  and  frequently 
beginning  at  night,  there  is  a  violent  outbreak  of  spasmodic  abdominal 
pain.  It  may  be  chiefly  umbilical,  or  epigastric,  or  diffuse  over  the 
entire  abdomen.  Schmidt^  states  that  it  is  often  accompanied  by 
sharp  lumbar  pain.  Vomiting  is  common.  During  the  paroxysm, 
the  abdominal  wall  is  usually  hard  and  retracted,  pressure  often  giving 
relief,  although  at  other  times  the  entire  abdomen  is  markedly  tender. 
Between  the  violent  spasms  which  last  a  few  minutes  the  patient  is  in 
comparative  comfort  for  a  short  interval.  The  severity  of  the  attack 
is  variable,  some  being  so  agonizing  as  to  cause  complete  prostration, 
while  others  are  tolerable.  It  may  last  from  a  few  hours,  or  with 
remissions  may  extend  over  several  days.  The  attacks  recur  at  various 
intervals  if  exposure  is  continued. 

The  distinguishing  characteristic  of  lead  neuritis  is  its  distribution. 
It  eventually  produces  bilateral  wrist  drop  from  paralysis  of  the 
extensors  of  the  fingers  and  wrists.  Less  frequently'  and  usually  later 
the  perinei  and  extensors  of  the  toes  and  ankles  become  involved. 
The  paralysis  may  become  quite  general,  progressing  from  the  per- 
iphery, or  more  rarely  other  atypical  forms  of  paralysis  may  appear 
at  first. 

Delirium,  coma,  convulsions,  epileptiform  or  unilateral,  or  variable 
are  the  most  striking  cerebral  symptoms.  They  are  always  dangerous, 
and  sometimes  of  extremely  grave  portent.  They  may  be  precipitated 
by  unusual  indulgence  in  alcohol,  and  are  said  to  occur  in  a  larger 
percentage  of  negroes  than  of  other  patients. 

There  is  no  constancy  in  the  order  of  appearance  of  the  different 
symptoms.  Colic,  paralysis,  or  even  coma  may  be  the  first  indication 
of  illness  to  the  patient  or  his  friends.  Other  constant  but  less  charac- 
teristic symptoms  are  evidences  of  arterial  and  cardiac  sclerosis,  of 
interstitial  nephritis  and  ocular  symptoms,  such  as  muscular  paralyses, 
hemianopsia,  and  general  and  gradual  impairment  of  vision.  Of  the 
ocular  disturbances  some  are  due  to  the  ence])hal()pathy,  others  to 
optic  neuritis,  and  neuritis  of  the  nerves  of  supply  of  the  external  eye 
muscles. 

'  Pain,  its  Causation  and  Diagnostic  Significance  in  Internal  Diseases,  1908. 


CHRONIC  LEAD  POISONING  fi05 

In  those  who  promptly  change  their  occujjation  or  withdraw  from 
the  source  of  exposure,  health  may  return  almost  completely.  If  the 
exposure  has  continued  for  some  time  the  resulting  damage  to  kidney, 
liver,  and  circulatory  system  may  continue  to  progress  even  after  the 
withdrawal  of  the  source  of  intoxication,  and  it  is  from  the  failure  of 
these  organs  that  death  most  often  occurs  in  those  who  escape  it  in 
the  encephalopathy. 

Diagnosis. — A  negative  history  of  exposure  has  little  value.  Where 
the  source  of  poisoning  is  clear,  any  failure  of  the  general  health  is  to 
be  viewed  with  suspicion,  and  when  the  characteristic  neuritis  or  colic 
are  added  to  the  picture  the  diagnosis  is  practically  certain.  The  asso- 
ciation of  "dry"  colic  and  neuritis  is  sufficient  to  make  lead  poisoning 
highly  probable,  and  the  addition  of  the  blue  line  makes  the  diagnosis 
certain. 

When  colic  is  a  prominent  symptom  extreme  care  must  be  exercised 
lest  an  acute  abdominal  inflammation  demanding  prompt  surgical 
treatment  be  overlooked  because  of  the  certainty  of  the  diagnosis  of 
lead  poisoning.  The  two  conditions  frequently  coexist,  some  authors 
even  going  so  far  as  to  state  that  acute  appendicitis  is  especially  frequent 
among  sufferers  from  lead  poisoning.  The  writer  once  saw  a  case  of 
acute  perforative  appendicitis  that  had  been  mistaken  for  lead  colic  by 
several  men  of  wide  experience.  The  patient  presented  all  the  signs  of 
lead  poisoning,  and  the  diagnosis  of  that  condition  was  unmistakably 
positive.  However,  he  was  sufficiently  stout  to  obscure  the  local 
abdominal  signs,  and  as  a  consequence  of  the  error  operation  was 
delayed  two  days.  General  suppurative  peritonitis  supervened,  and 
a  fatal  termination  soon  followed. 

The  blue  line  when  present  and  distinct  is  strong  corroborative 
evidence,  but  if  the  gums  and  teeth  are  in  good  condition  it  may  be  very 
slight  and  poorly  defined.  It  is  also  absent  in  some  early  cases  which 
give  symptoms.  It  is  almost  universally  agreed  that  the  most  reliable 
single  sign  in  all  stages  of  the  disease  is  the  granular  basophilia  of  the 
red  cells  when  out  of  proportion  to  the  grade  of  anemia.  Cabot^  main- 
tains that  lead  is  the  only  disease  which  often  produces  basophilic 
stippling  in  the  red  cells  in  the  absence  of  marked  anemia,  and  states 
also^  that  he  has  never  known  a  clear  case  of  plumbism  without  stippling. 
The  presence  of  lead  in  the  urine  is  of  great  value  in  diagnosis,  its 
absence  is  less  helpful,  for  it  is  quite  probable  that  it  may  disappear 
from  the  urine  intermittently  for  short  periods. 

Treatment. — A  discussion  of  the  manifold  features  of  the  prophylaxis 
of  chronic  lead  poisoning  in  the  industries  is  out  of  place  here;  it  may  be 
summed  up  as  cleanliness  of  hands  and  skin,  reduction  of  dust  and  all 

1  Differential  Diagnosis,  1911,  j).  132.  -  Ibid.,  p.  1.52. 


606      VARIOUS  DISEASES  AND   THEIR  GASTRIC  RELATIONS 

other  possibilities  of  exposure  to  a  minimum,  and  strict  avoidance  of 
constipation.  The  free  use  of  milk  has  the  reputation  of  being  a 
powerful  preN'entive,  probably  because  it  not  only  combines  with  the 
hydrochloric  acid  in  the  stomach,  thus  leaving  less  to  form  the  soluble 
lead  chloride,  but  also  because  it  forms  an  insoluble  albuminate  with 
the  lead. 

A  person  suffering  from  chronic  lead  poisoning  must  be  removed 
from  the  source  of  intoxication  if  possible.  The  further  treatment  con- 
sists in  the  elimination  of  the  lead  from  the  system  and  the  treatment 
of  the  special  symptoms  present.  Elimination  is  best  promoted  by 
moderate  catharsis  with  magnesium  sulphate,  together  with  atropine 
for  its  antispasmodic  effect  when  there  is  severe  colic,  and  enemas, 
simple  or  of  oil,  or  containing  magnesium  sulphate.  The  magnesium 
sulphate  is  the  l)est  of  the  saline  cathartics  to  use  for  this  purpose, 
because  it  forms  the  insoluble  lead  sulphate  with  that  portion  of  the 
lead  which  is  free  in  the  intestine. 

Potassium  iodide  not  only  increases  the  elimination  in  general,  but 
probably  also  forms  the  soluble  double  iodide  of  lead  and  potassium, 
in  which  form  it  is  excreted,  but  in  the  presence  of  acute  symptoms 
this  drug  must  be  used  with  caution,  for  it  sometimes  causes  an  increase 
in  the  toxic  manifestations  supposed  to  })e  due  to  the  sudden  libera- 
tion in  the  body  of  so  much  lead  in  soluble  form.  Not  over  five  or  at 
the  most  ten  grains  three  times  a  day  should  be  used,  and  then  not 
without  careful  watching  for  toxic  symptoms. 

For  the  colic  hot  moist  abdominal  applications,  hot  baths,  and  anti- 
spasmodics are  helpful,  and  finally  morphine  must  be  resorted  to  in 
many  cases,  although  it  checks  the  process  of  elimination.  The  neuritis 
and  encephalopathies  are  treated  on  the  lines  governing  the  treatment 
of  these  conditions  when  due  to  other  causes. 


INDEX 


Abscess.     See  Pus. 

in  perforation  of  gastric  ulcer,   164, 

165 
in  phlegmonous  gastritis,  35 
of  liver,   difTerentiatecl  from  phleg- 
monous gastritis,  36 
perigastric,  in  cancer,  267 
peritoneal,  differentiated  from  phleg- 
monous gastritis,  36 
subphrenic,  164 
in  cancer,  267 
Achylia  gastrica,  50,  481,  563 

abdominal  distress  and  disten- 
tion in,  498 
character  of  stools  in,  497 
complicated    with    gall-bladder 
disease     and    gallstones, 
500 
with  gastroptosis,  501,  502 
diagnosis  of,  503 
diarrhea  in,  496 
dry,  73,  503 

due    to    atrophic     changes    in 
stomach,  485 
to  functional  derangement, 

487 
to  gastric  catarrh,  482 
forms  of,  481 
gastric  analysis  in,  57,  503 

symptoms  of,  495 
heart-burn  in,  495 
intestinal  symptoms  of,  496 

toxemia  in,  498 
latent  course  of,  494 
lavage  in,  509 
malignant,  481 
medicinal  treatment  of,  508 
nature  of,  482 
non-malignant,  481 
pathology  of,  482 
relation  of,  to  alcoholic  gastritis, 
70,  73,  74 
to  chronic  gastritis,  50 
to  gall-bladder  disease,  490, 

500,  578 
to  gallstones,  501,  502 
to    gastroptosis,    493.    501, 

502 
to  other  di.seases,  489 


Achylia  gastrica,  symptoms  of,  494 
temporary,  488 
treatment  of,  506 
dietetic,  64,  506 
lavage  in,  509 
medicinal,  508 
wet,  57,  73,  74,  504 
with  complications,  499 
with  stagnation,  503 
Acid  catarrh  of  stomach,  47.    See  Gastri- 
tis with  hyperacidity. 
Acidity.     See   Hyperacidity. 

in  gastritis,  catarrhal,  chronic,  47 
Acoria,  544 

Adenocarcinoma  of  stomach,  219 
Adenoma,  289 

pedunculated,  289 
symptoms  of,  292 
treatment  of,  292 
Adhesions,  accompanying  ulcer,  gastric, 
chronic,  168 
as  cause  of  hour-glass  stomach,  393 

of  pyloric  stenosis,  351 
in  gastric  ulcer,  168 
Aerophagia,  553.    See  Eructations. 

with  gastralgia,  550 
Alcoholic    gastritis,    70.     See    Gastritis, 

alcoholic. 
Anacidity,     chronic    catarrhal     gastritis 

with,  50 
Anadenia  gastrica,  482 

ventricuh,  46 
Anemia  in  cancer,  235 
Angina  abdominalis,  582 
Angioma,  292 
Angulator    for    measurement     of    costal 

angle,  441 
Anorexia,  544 
Appendicitis.     See  Appendix. 

accompanying  hypersecretion,  516 
acute,  568 

pain  in,  568 
and  pylorospasm  in  hypersecretion, 

521 
as  cause  of  atony,  314 
chronic,  568 

course  of,  576 
diagnosis  of,  575 
gas  type  of,  574 
nausea  type  of,  572 
pain  type  of,  568 


(iOS 


INDEX 


Appendicitis,   chronic,  physical  signs  of, 
576 
symptoms  of,  568 

gastric,  568 
treatment  of,  576 
.    vomiting  type  of,  573 
differentiated  from  acute  gastritis,  22 
from  dietetic  gastritis,  22 
from  hypersecretion,  528 
from  perforation  of  gastric  ulcer, 

167 
from  visceral  crises  in  erythe- 
mas, 599 
forms  of,  568 
gastric  relations  of,  568 
pain  of,  differentiated  from  that  of 
gastric  ulcer,  116 
Ajjpendicular  gastralgia,  570 

indigestion,  571.      (SVe  Appendicitis. 
Appendix,    diseases   of,    associated    with 
pyloric  spasm,  348,  349 
dififerentiated  from  hyperacid- 
ity, 474 
pylorospasm  with,  348 
dyspepsia,  348 
Appetite,  disorders  of,  543 
in  atony,  317 

in  chronic  catarrhal  gastritis,  51 
loss  of,  in  cancer,  234 
Arteriomesenteric  constriction,  and  acute 
dilatation,  334,  339,  590 
and  gastroptosis,  434 
gastric  relations  of,  590 
Arteriosclerosis,  diagnosis  of,  584 
etiology  of,  579 
flatulence  in,  580 
gas  type  of,  580 
gastric  relations  of,  579 
pain  of,  differentiated  from  that  of 

gastric  ulcer,  117 
pain  type  of,  582 
prognosis  of,  584 
symptoms  of,  580 
treatment  of,  585 
Ascites  in  cancer,  244,  270 
Atony  of  stom,ach,  309 
acute,  325 

age,  influence  of,  on,  311 
apjjcndicitis  as  cause  of,  314 
appetite  in,  317 
chlorosis  in,  313 
chronic  exhausting  diseases  in. 

313 
constipation    as   cause   of,    314, 

316 
course  of,  325 
diagnosis  of,  317 

radiographic,  319 
differ(>ntiated  from  pyloric  sten- 
osis, 311 
dizziness  in,  317 
enteroptosis  in,  313 
etiology  of,  312 

excess   in  eating   ;ui<l   (h-inl<iiig, 
as  cause  of,  313 


Atony  of  stomach,  faradism  in,  329 
filling  of  stomach  in,  310 
flatulence  in,  315 
gall-bladder    diseases   as   cause 

of,  314 
gastric  analysis  in,  321 
gastritis  as  cause  of,  314 
gastrodiaphany  in,  318 
gastroptosis  in,  318 
general  causes  of,  312 
headache  in,  317 
heart-burn  in,  317 
heaviness  and  sense  of  weight 

in,  316 
iced  water  as  cause  of,  314 
inflation  of  stomach  in,  319 
inspection  in,  318 
intestinal  distress  in,  316 
irrigation  in,  331 
local  causes  of,  313 
massage  in,  330 
morbid  apprehension  and  fears 

in,  317 
nausea  in,  316 
neurasthenia  in,  312 
occurrence  of,  311 
pain  in,  315 
palpation  in,  319 
pelvic  disorders  as  cause  of,  314 
percussion  in,  319 
physical  signs  of,  317 
purgatives  as  cause  of,  314,  329 
recurrent,  325 
reflex  causes  of,  314 
rest  in,  329 

sex,  influence  of,  on,  311 
shape  of  stomach  in,  321 
splashing  sounds  in,  319 
succussion  sounds  in,  319 
.symptoms  of,  315 
tests  for  motility  in,  323 
treatment  of,  326 

dietetic,  326 

hydrotherapy  in,  330 

medical,  327 

physical,  329 
tumors  as  cause  of,  314 
vomiting  in,  317 
Autodigestion,  101 
Autosuggestion,  dietetic  gastritis  and,  IS 

B 

Bacillus  botulinus    in    infectious    gas- 
tritis, 25 
enteritidis  in  infectious  gastritis,  24 

Bacteria  in  dietetic  gastritis,  18 
in  infectious  gastritis,  24,  25 
in  membranous  gastritis,  28 
in  ])hlegmonous  gastritis,  31,  32 

Blood  in  cancer,  235 

Botulism,  25 

symptoms  of,  26 

lireast  changes  in  gastroptosis,  437 

Bulimia,  543 


INDEX 


609 


Cancek,  210 

age,  influence  of,  on,  211 

anemia  in,  235 

as  cause  of  hour-glass  stomach,  393 

of  pyloric  stenosis,  353,  366 
ascites  iil,  244,  270 
associated   with    gastric    dilatation, 

250 
blood  in,  235 
cessation  of  pain  in,  227 
changes    in    mucous    membrane  of 
stomach  in,  222 
in  position  of  tumor  in,  248 
in  shape  of  stomach  in,  222 
chemical  examination  in,  255 
clinical  types  of,  237 
anemic,  237 
dry,  shrivelled,  237 
growths  involving  cardiac   ori- 
fice, 240 
pyloric  orifice,  240 
not  involving  either  orifice, 
.240 
when   both   general   and    local 

symptoms  prevail,  240 
when    general    symptoms     pre- 
dominate, 237 
when     local     symptoms      pre- 
dominate, 238 
when  symptoms  due  to  metas- 
tases predominate,  241 
colloid,  220 
coma  in,  237 
complement  deviation  reactions  in, 

261 
complications  in,  266,  270 
cyhndrical  cell,  219 
density  of  tumor  in,  248 
development  of,  in  ulcer,  153,  155 
diagnosis  of,  271 
early  cases,  271 
late  cases,  271 

specific  test  proposed  for,  260 
differentiated  from  achylia,  57 
from  cirrhosis,  87 
from  dietetic  gastritis,  22 
from  hyperacidity,  473 
from  sai'coma,  285 
dilatation  associated  with,  250 
duration  of,  271 
encephaloid,  217 
failure  in  nutrition  in,  236 
fasting  stomach  in,  examination  of, 
254,  257 
motor  errors  in,  254 
normal,  254 
fever  in,  236 
fistulas  in,  268 
frequency  of,  210 

of  different  types  of,  221 
gastric  analysis  in,  253 
gastritis,     phlegmonous,     associated 
'  with,  271 
39 


/• 


Cancer,  gastrojejunostomy  for,  276 
glandular,  214 
hemoglobin  in,  235 
hemorrhages  in,  232,  239 

occult,  233 

visible,  232 
heredity,  influence  of,  on,  211 
indigestion  prior  to,  224 
inspection  in,  245 
involvement  of  liver  in,  244,  269 

of  pelvis  in,  244 

of  perigastric  glands  in,  243 

of  retroperitoneal  glands  in,  243 

of  supraclavicvdar  glands  in,  243 

of  umbiUcal  ring  in,  245 
isohemolysis  reactions  in,  263 
location  of  tumor  in,  247 
loss  of  appetite  in,  234 
lung  complications  in,  270 
medullary  (soft)  form  of,  217 
meiostagmin  reactions  in,  263 
metastases  in,  241,  269 

by  direct  invasion,  241 

by  lymphatics,  243 

by  venous  channels,  243 

in  fiver,  244,  269 
motility  of  tumor  in,  248 
pain  in,  225 

cessation  of,  227 
palpation  of,  246,  250 
pathology  of,  213 
perforation  in,  266 
perigastric  abscess  in,  267 
peritonitis  in,  266,  269 
physical  signs  of,  245 
pneumonia  in,  270 
polyneuritis  in,  270 
precancerous  history  of,  223 
pruritus  in,  236 
pyloric,  in  hypersecretion,  521 
race  influence  of,  on,  210 
relation  of,  to  cirrhosis,  76 

to  dilatation,  250 

to  hypersecretion,  515,  521 

to  pyloric  ulcer,  370 
rigidity  of  tumor  in,  250 
Salomon's  test  in,  263 
scirrhous  (hard)  form  of,  214 
serological  tests  for,  261 
specific  tests  for,  260 
spheroidal  cells,  214 
subphrenic  abscess  in,  267 
symptoms  of,  223 

general,  234 

local,  225 
test  breakfast,  abnormality  of,  259 
examination  of,  in,  257 
normal,  258 
thrombosis  in,  270 
traumatism,  influence  of,  on,  212 
treatment  of,  274 

diet  in,  274 

drugs  in,  274 

lavage  in,  275 

surgical,  276 


610 


INDEX 


Cancer,  tryptoj)han  tests  in,  264  I 

tumor  in,  240,  250 

shape  of,  248  | 

size  of,  248  t 

types  of,  214  j 

frequency  of,  221 
ulcer  as  origin  of,  153,  155,  223,  370  j 
umbilical  ring  involved  in,  245  I 

urine  in,  236  • 

vomiting  in,  228,  230,  238,  268 
x-ray  examination  in,  251 
Carcinoma.     See  Cancer, 
colloid,  220 
cylindrical  cell,  219 
glandular,  214 
spheroidal  cell,  214 
Cardiac  orifice,  cancer,  involving,  240 
Catarrh  of  stomach,  secondary,  43 
Chlorosis  in  atony,  313 
Cholecystitis,  pylorospasm  with,  347 
Cholelithiasis,  pylorospasm  with,  347 
Chvostek's  phenomenon  in  gastric  tetany, 
358 
in  pyloric  stenosis,  358 
Cicatricial  contractions  in  gastric  ulcer, 

170 
Cicatrix  from  ulcer  as  cause  of  pyloric 

stenosis,  351 
Cirrhosis    of    liver,    differentiated    from 
cirrhosis  of  stomach,  87 
of  stomach,  76 

cancer,  relation  of,  to,  76 
diagnosis  of,  85 

differential,  87 
differentiated  from  benign  sten- 
osis, 87 
from  cancer,  87 
from  cirrhosis  of  liver,  87 
from  syphilis,  87 
from     tuberculous     perito- 
nitis, 88 
diffuse  form  of,  81 
duration  of,  88 
etiology  of,  78 
gastric  analysis  in,  83,  85 
hematemesis  in,  84 
localized  form  of,  79 
melena  in,  84 

microscopical  examination  in,  82 
nature  of,  76 
pain  in,  84 
pathogenesis  of,  76 
pathology  of,  79,  81 
physical  examination  in,  85 
prognosis  of,  88 
symptoms  of,  82,  84 
syphilitic,  307 
treatment  of,  88 
dietetic,  89 
medical,  88 
surgical,  89 
ulcer,  relation  of,  to,  78 
\  oiniting  in,  SI 
\('titriciili,  216 
Citonliobia  doloi'osa,  531 


Colic,  differentiated  from  visceral  crises 
in  erythemas,  599 
in  chronic  lead  poisoning,  605 
in  visceral  crises  of  erythemas,  598 
Colitis  in  gastroptosis,  437 
Collapse  in  perforation  of    gastric  ulcer, 

162 
Coloptosis  in  gastroptosis,  443 
Coma  in  cancer,  237 

carcinomatosum,  237 
Complement  deviation  reaction  in  cancer, 

261 
Concretions  in  stomach,  294 
Constijiation    in  atony  of  stomach,  314, 
316 
in  hyperacidity,  464 
in  hypersecretion,  acute,  513 

alimentary,  534 
in  pyloric  stenosis,  356 
Curling's  ulcer,  209 
Cynorexia,  543 
Cysts  in  stomach  wall,  292 
dermoid,  293 
hydatid,  293 


Dermoid  cyst,  293 
Diaphragm,  eventration  of,  413 
Diaphragmatic  hernia,  399 
acquired,  403 
associated     with     volvulus     of 

stomach,  419 
congenital,  399 

mechanism  of,  402 
diagnosis  of,  407 

differential,  410 
differentiated  from  eventration, 
410,  413 
from  pneumothorax,  410 
forms  of,  399 
hemorrhage  in,  405 
mechanism  of,  400,  402 
pain  in,  405 

paradoxical  expiratory  displace- 
ment in,  410 
partial,  411 
l)hysical  signs  in,  407 
l)r()gnosis  of,  411 
rare  forms  of,  411 
Richter's,  411 
Roentgen  ray  in,  408 
strangulation  in,  406 
sym])toms  of,  403 
of  accjuired,  406 
of  congenital,  403 
of  traumatic,  405 
traumatic,  402 
treatment  of,  411 
viscera  concerned  in,  400 
vomiting  in,  405 
with  gastioptosis,  412 
Diarrhea  in  adiylia  gastrica,  496 

in  gastritis,  cafan-lial,  chronic,   IS 


INDEX 


(III 


Diarrhcii  in  j;;;istritis,  dick'tic,  21 
infectious,  26 
toxic,  39 
in  hypei-jicidity,  468 
in  pyloric  stenosis,  356 
Dietetic  errors  aiul  dietetic  gastritis,  18, 
19 
a  cause  of  liyjienicidity,  462 
Dietl's  crises  in  gaslroptosis,  43S 
Dilatation,  acute,  oi'  stonuicli,  333 

and  arteriomesenteric  con- 
striction, 334,  590 
anesthetic  as  cause  of,  340 
associated  with  cancer,  250 
causes  of,  335,  339 
collapse  in,  342 
complicating   pneumonia, 

338 
diagnosis  of,  343 
differentiated  from  obstruc- 
tion, 343 
from     postoperative 

ileus,  343 
from  volvulus  of  stom- 
ach, 425 
duodenal  kinks  as  cause  of, 

336 
etiology  of,  340 
excessive  eating  and  drink- 
ing as  cause  of,  340 
exciting  causes  of,  340 
infections  as  cause  of,  341 
intragastric     pressure     as 

cause  of,  337 
lavage  in,  344 
mechanical  theory  of.  335 

weight  as  cause  of,  336 
mechanism  of,  334,  339 
mesenteric    constriction    as 

cause  of,  335,  590 
operations  as  cause  of,  340 
pain  in,  341 

paralytic  theory  of,  337 
paresis  of  central  origin,  as 

cause  of,  337 
pathology  of,  333 
physical  signs  of,  342 
postanesthetic     paresis     as 

cause  of,  337 
prognosis  of,  343 
summary  of  mechanism  and 

causes  of,  339 
symptoms  of,  341 
S3monyms  of,  333 
temperature  in,  342 
toxic  paresis   as    cause    of, 

338 
traumatism  as  cause  of,  340 
treatment  of,  344 
medical,  345 
postiu-e  in,  345 
surgical,  345 
vomiting  in,  341 
gastric,    350,    351.      Sep    Dilatation, 
acute,  of  stomach. 


Dilalation,  gastric,   a.'^sociatcd  witli   can- 
cer, 250 
paradoxical  of  .Jaworski,  395 
postoperative,  333.     See  Dilata- 
tion, acute,  of  stomach. 
Dizziness,  in  atony  of  stomach,  317 

in  gastroptosis,  436 
Douleur  thoracique  in  volvulus  of  stom- 
ach, 423 
Drowsiness  in  chronic  catarrhal  gastritis, 

49 
Duodenal  kinks  causing  dilatation,  336 
obstruction,  587 

regurgitation  due  to  excessive  fat   in 
diet,  591 
Duodenojejunal  kinks,  587 
diagnosis  of,  590 
gastric  relations  of,  587 
intestinal  stasis  in,  589 
pain  in,  588 
symptoms  of,  588 
treatment  of,  590 
vomiting  in,  588 


E 


Eating  and  drinking,  excessive,  as  cause 
of  atony,  313 
as  cause  of  dilatation,  340 
errors  in,  cause  of  acute  gastritis,  19 
Einhorn's  duodenal  alimentation,  188 
Emaciation  in  chronic  catarrhal  gastritis, 
52 
in  hypersecretion,  533 
Empyema  of  the  bursa  omentalis,  164 
Enteroptosis,  426.    See  Gastroptosis. 
in  atony  of  stomach,  313 
in  children,  430 
Landau's,  427 
Enteroptotic  habit,   313,   427,   429,   438, 

439 
Epigastralgia,  548,  550 
Epigastric  hernia,  600 

etiology  of,  600 
pain  in,  601 

physical  examination  in,  601 
symptoms  of,  601 
treatment  of,  602 
vomiting  in,  601 
Epithelioma  of  stomach,  223 
Erb's  phenomenon  in  gastric  tetany,  358 

in  pyloric  stenosis,  358 
Erosions,  hemorrhagic,  192 
acute,  192 
chronic,  197 

due  to  volvulus  of  stomach,  418 
etiology  of,  194 
hemorrhage  in,  195,  197 
pain  in,  195,  197 
prognosis  of,  196 
relation  of,  to  ulcer,  99 
symptoms  of,  195 
treatment  of,  196,  198 
Eructations,  553.    See  Aerophagia. 


612 


INDEX 


Eructations  in  chronic  catarrhal  gastritis, 

52 
Erythemas,  visceral  crises  in,  595 
Erythematous  diseases  differentiated 

from  perforation  of  gastric  ulcer,  167 
Etat  mamelonne  in  chronic  gastritis,  45 
Eventration  of  diaphragm,  413 

differentiated     from     diaphrag- 
matic hernia,  410,  413 
physical  signs  of,  415 
symptoms  of,  415 
treatment  of,  415 
x-ray  in  diagnosis  of,  410,  414 


Fever.     See  Temperature, 
in  cancer,  236 
in  gastritis,  dietetic,  21 
infectious,  26,  27 
phlegmonous,  34,  35 
in  sarcoma,  281 
Fibroid  induration,  76.     See  Cirrhosis  of 

stomach. 
Fibromyoma,  286 
external,  288 
internal,  288 
submucous,  288 
subserous,  288 
symptoms  of,  288 
treatment,  289 
Fibrosis,    gastric,    76.      See   Cirrhosis   of 
stomach, 
generalized,  81 
localized,  79 
Fistulas  associated  with  cancer,  268 
Flatulence,  550 

in  appendicit  is,  574 
in  arteriosclerosis,  580 
in  atony  of  stomach,  315 
in  dietetic  gastritis,  21 
nervous,  553 
Food,  errors  in,  cause  of  a(!ute  gastritis,  18 
poisoning,   24.     See  Gastritis,   infec- 
tious. 
Foreign  bodies  in  stomach,  293 

gastric  concretions,  294 
hair  balls,  293,  295 
liardware,  294,  296 
living  creatures,  294,  297 
symptoms  of,  295 
treatment  of,  297 
vegetable  balls,  294,  296 


G 


(iALL-BLADDER,  (liseascs  of,  and  achylia, 
relation  of,  490,  500,  578 

and  hyperacidity,  relation  of,  473, 
578 

as  cause  of  atony,  314 

asisociated  with  pyloric  spasm,  347, 
349 


Gall-bladder,   diseases   of,   differentiated 
from  acute  gastritis,  22 
from  dietetic  gastritis,  22 
from  gastric  indigestion,  577 
from  hyperacidity,  473 
from  hypersecretion,  528 
forms  of,  577 
gastric  relations  of,  576 
pain  in,  577,  578 

differentiated  from  pain  of  gas- 
tric ulcer,  117 
pylorospasm  in,  578 
rupture  of,  differentiated  from  per- 
foration of  gastric  ulcer,  168 
Gallstones  and  achylia  gastrica,  relation 
of,  501,  502 
and   hyperacidity,   relation   of,    473, 

578 
and  hypersecretion,  relation  of,  521 
differentiated   from   gastric   indiges- 
tion, 577 
from  hyperacidity,  473 
from  hypersecretion,  528 
forms  of,  577 
gastric  relations  of,  576 
jaundice  in,  577 
pain  in,  577,  578 
pylorospasm  and,  521,  578 
Gartner's  bacillus  and  infectious  gastritis, 

24 
Gas.     See  Flatulence. 
Gastralgia,  548 

appendicular,  570 
Gastrectasis,  acute,  333.    See  Dilatation, 

acute. 
Gastric  acidity,  no  standard  of  normal, 
461 
variations  in,  461 
concretions  in  stomach,  294 
crises  of  tabes  dorsalis,  591 
diagnosis  of,  594 
duration  of,  593 
frequency  of,  592 
gastric  analysis  in,  594 
pain  in,  592 
symptoms  of,  592 
treatment  of,  594 
vomiting  in,  592 
fibrosis,  76.  See  Cirrhosis  of  stomach, 
indigestion,  differentiated  from  gall- 
gladder  diseases,  577 
Gastritis,  acute,  17.    See  Gastritis,  catar- 
rhal,   acute;    gastritis,    mem- 
branous; gastritis,  phlegmon- 
ous; and  gastritis,  toxic, 
catarrhal,     17.      See    Gastritis, 
dietetic;  and  gastritis,  infec- 
tious, 
febrile,  of  children,  21 
interstitial,    31.     See   Gastritis, 

phlegmonous, 
pain  in,  568 
alcoholic,  70 

achylia  in,  73,  74 
clinical  history  of,  72 


INDEX 


613 


CJas Iritis,  alcoholic,  diagnosis  of,  73 
etiology  of,  70 
gastric  analysis  in,  73 
nausea  in,  71    . 
pain  in,  71 
pathology  of,  70 
prognosis  of,  74 
symptoms  of,  70 
treatment  of,  74 
vomiting  in,  71 
anacid,  symptoms  of,  51 
atrophic,  43 

catarrhal,  acute,   17.     Hee  Gastritis, 
dietetic,   and  gastritis,   infec- 
tious, 
chronic,  46 

acidity  in,  47 
appetite  in,  51 
clinical  types  of,  46 

symptoms  in,  49 
course,  59 
diagnosis  of,  53 
diarrhea  in,  48 
differentiation  of  symptoms 

in  different  types  of,  49 
drowsiness  in,  49 
duration  of,  59 
emaciation  in,  52 
eructations  in,  52 
gastric  analysis  in,  53,  55, 

56,  57 
gnawing  sensation  in,  50 
heart-burn  in,  47,  52 
headache  in,  49 
nausea  in,  51 
negative  symptoms  of,  51 
pain  in,  52 
Penzoldt's  diet  in,  60 
treatment  of,  59 

dietetic,  60,  63,  64 
lavage  in,  66 
medicinal,  64 
prophylactic,  59 
vomiting  in,  52 
with  anacidity,  50 
diet  in,  64 

gastric  analysis  in,  57 
symptoms  of,  51 
with  hyperacidity,  47 
acidity,  type  of,  47 
diarrhea,  type  of,  48 
diet  in,  63 

gastric  analysis  in,  55 
toxemia,  type  of,  49 
with  normal  acidity,  50 
diet  in,  64 

gastric  analysis  in,  56 
with  subacidity,  50 
chronic,  42.    See  Gastritis,  catarrhal, 
chronic;    and    gastritis    alco- 
holic, 
achylia  gastrica,  relation  of,  to, 

50 
alcoholic,  70.    See  Gastritis  alco- 
holic. 


Gastritis,  chronic,  atrojihic   type,  43,  44, 
46 
catarrhal,     46.      See    (iastritis, 

catarrhal,  chronic. 
(5tat  mamclonne  in,  45 
etiology  of,  42 
interstitial,  76.    See  Cirrhosis  of 

stomach, 
pathology  of,  44 
primary,  42 
productive  type,  44 
secondary,  42,  43 
tyjjes  of,  46 
croupous,   28.     See  Gastritis,  mem- 
branous, 
cystica,  46 
dietetic,  17 

autosuggestion  and,  18 
bacteria  and,  18 
diagnosis  of,  22 
diarrhea  in,  21 

differentiated  from  appendicitis, 
22 
from  cancer,  22 
from    gall-bladder    disease, 

22 
from  ulcer,  22 
duration  of,  21 
errors  in  eating,  and,  19 

in  food  and,  18 
etiology  of,  17 
exciting  causes  of,  18 
fever  in,  21 
flatulence  in,  21 
pain  in,  20,  21 
pathology  of,   19 
recurrences  in,  22 
symptoms  of,  20 
treatment  of,  22 
vomiting  in,  20 
diphtheritic,  28.    See  Gastritis,  mem- 
branous, 
hyperacid,  47 
diet  in,  63 

differentiated  from  hyperacidity, 
474 
hyperpeptic,  47 
hypertrophic     stenosing,     70.       See 

Cirrhosis  of  stomach, 
infectious,  24 

bacillus  botulinus  and,  25 

enteritidis  and,  24 
bacteria  and,  24,  25 
diarrhea  in,  26 
eruptions  in,  26 
etiology  of,  24 
fe^-er  in,  26,  27 
Gartner's  bacillus  and,  24 
paratj^phoid  bacillus  and,  25 
prostration  in,  26 
symptoms  of,  26 
treatment  of,  27 
tyrotoxicon  and,  25 
urine  in,  26 
vomiting  in,  26 


ou 


INDEX 


fiastritis,  membranous,  28 

bacteria  and,  28 

etiolog\'  of,  28 

Klebs-IiOcffler  bacillus  and,  28 

pathology  of,  28 

prognosis  of,  30 

pus  in,  30 

symptoms  of,  30 

treatment  in,  30 

vomiting  in,  30 
phlegmonous,  31 

accomj)anying  gastric  ulcei',  172 

bacteria  and,  31,  32 

circumscribed  form  of,  34,  35 
pathology,  34 
sj^mptoms,  35 

complicating  cancer  of  stomach, 
271 

diagnosis  of,  35 

differentiated    from    abscess    of 
liver,  36 
from  peritoneal  abscess,  3G 

dilTuse  form  of,  33 
pathology,  33 
symptoms,  34 

dm-ation  of,  36 

etiolog}'  of,  31 

fever  in,  34,  35 

frequency  of,  31 

jaundice  in,  35 

mental  phenomena  in,  34 

pain  in,  34 

pathology  of,  32,  33,  34 

prognosis  of,  36 

prostration  in,  34,  35 

pus  in,  34,  35 

sj'mptoms  of,  34,  35 

treatment  of,  36 

vomiting  in,  34,  35 

with  ulcer,  172 
polyposis,  290 

simple,  17.     See  Gastritis,  dietetic, 
toxic,  37 

diagnosis  of,  40 

diarrhea  in,  39 

etiology  of,  37 

hemorrhage  in,  39 

jaundice  in,  39 

pain  in,  39 

pathology  of,  37 

prognosis  of,  40 

slough  in,  37 

symi)toms  of,  39 

treatment  of,  40 

urin(^  in,  39 

vomiting  in,  39 
with  hyperacidity,  47 
with  normal  acidity,  diet  in,  64 
Gastrodiaphane,  318 
Gastrodiaphany,  318 
Gastrojejunostomy,  after  treatment  of, 
207 
for  cancer,  276 

gastrojejunal  ulcer  following,  198 
jejunal  ulcer  following,  198 


Gastrokenosis,  544 
Gastroptosia,  426.     See  Gastroptosis. 
Gastroptosis,    achylia   gastrica,    relation 
of,  to,  493,  501,  502 
acquired  form  of,  427 
arteriomesenteric  constriction  in,  434 
belt  in  treatment  of,  450 
breast  changes  in,  437 
circulation  in,  437 
colitis  in,  437 
colon  in,  437,  443 
coloptosis  in,  443 
congenital  form  of,  429 
diagnosis  of,  443 
Dietl's  crises  in,  438 
dizziness  in,  436 
enteroptotic  habit,  427,  429,  438 
etiology  of,  427 
frequency  of,  426 
gastric  analysis  in,  443 
hemorrhage  in,  435 
in  children,  430 
insomnia  in,  436 
inspection  in,  438 
jugulopubic  index,  439 
kidney  displacement  in,  438,  443 
liver  displacement  in,  438 
nausea  in,  435 
obstruction  in,  434 
occurrence  of,  426 
pain  in,  434,  435 
peristalsis  in,  443 
physical  signs  of,  438 
prognosis  of,  445 
prophylaxis  of,  445 
skin  in,  437 
stomach  in,  430 

drain-trap  form  of,  431 

fish-hook  form  of,  431 

looped  form  of,  431 

position  of,  430 

shape  of,  430 

water-trap  form  of,  431 
strapping  in  treatment  of,  452 
symptoms  of,  431,  433,  434 

tlue  to  associated  displacements, 
437 

nervous,  437 

of  atony,  434 

of  neurasthenia,  435 

of  subnutrition,  435 
toxic,  437 

tight  lacing  and,  428 
treatment  of,  445 

ambulant,  446 

corset  in,  450 

dietetic,  446 

drug,  447 

hygienic,  449 

medical,  446 

prophylactic,  445 

rest   cure,  455 

surgical,  457 
volvulus  of  stomach,  relation  of,  to, 
422 


INDEX 


615 


Ci;i-str(jpl(j.si.s  willi  ulony,  318,  432 
symptoms  of,  434 
with  diaphragmatic  hernia,  412 
without  atony,  432 
x-ray  examination  in,  442 
Gastrosuccorrhea,  510.    See  Hypersecre- 
tion. 
Gastroxynsis,  513 
Gumma  of  stomach,  303,  300 


H 


Habitus   enteroptoticus,  313,  427,    429, 
438,  439 
paralyticus,  429 
Hair  balls  in  stomach,  293,  295,  296 
Hardware  in  stomach,  294,  296 
Headache,  bilious,  317 

in  atony  of  stomach,  317 
in  chronic  catarrhal  gastritis,  49 
in  hyperacidity,  46S 
in  hypersecretion,  513 
sick,  317 
Heart-burn  in  achylia  gastrica,  495 
in  atony  of  stomach,  317 
in    chronic    catarrhal    gastritis,    47, 

52 
in  hyperacidity,  465,  472 
Hematemesis.     See  Hemorrhage. 
Hemorrhage  in  cancer,  232,  233,  239 
in  cirrhosis  of  stomach,  84 
in  erosions,  195,  197 
in  gastric  ulcer,   99,    127,    128,   130, 

187,  301 
in  gastritis,  toxic,  39 
in  gastroptosis,  435 
in  hernia,  diaphragmatic,  405 
in  hyperacidity,  468,  472 
in  sarcoma,  282 
in  tuberculous  ulcers,  301 
submucous,  relation  of,  to  ulcer,  99 
Hernia,    diaphragmatic,    399.     ^ee   Dia- 
phragmatic hei'nia. 
epigastric,       600.     See       Epigastric 

hernia, 
of  linea  alba,  600 
Heterochylia,  487,  564 
Hour-glass  contractions  in  gastric  ulcer, 
171 
in  volvulus  of  stomach,  421 
stomach,  392 

acquired  form  of,  392 
cancer  as  cause  of,  393 
congenital  form  of,  392 
etiology  of,  392 
forms  of,  392 
hypertonic,  396 
hypotonic,  397 
organic,  395 
physical  signs  of,  394 
radiographic  diagnosis  of,  395 

examination  in,  394 
spastic,  396 
symptoms  of,  394 


Hour-^lu.ss  .stoiiiacli,  tests  for,  395 
treatment  of,  398 
surgical,  398 
Hunger  pain  in  chronic  gastric  ulcer,  114 
Hydatid  cyst,  293 
Hyperacidity,  459,  563 

constipation  as  cause  of,  464 
course  of,  475 
diagnosis  of,  469,  474 
differential,  471 
practical  rules  for,  474 
diarrhea  in,  468 
dietetic  errors  as  cau.se  of,  462 
differentiated     from     appendicular 
disease,  474 
from  cancer,  473 
from  gall-bladder  infection,  473 
from  gallstones,  473 
from  hyperacid  gastritis,  474 
from  hypersecretion,   459,   472, 

531 
from  ulcer,  472 
due    to    gall-bladder    infection    and 

gallstones,  473 
etiology  of,  459,  462 
frequency  of,  460 
functional,  465.     See  Hyperacidity, 

primary, 
gastric  analysis  in,  469 
symptoms  in,  465 
negative,  467 
ulcer  and,  135 
gastritis,  catarrhal,  with,  47 
headache  in,  468 
heart-burn  in,  465,  472 
hemorrhages  in,  468,  472 
larval,  470 

differentiated  from  hypersecre- 
tion, 531 
motor  errors  as  cause  of,  463 
nervous  causes  of,  464 
pain  in,  465,  467,  472 
physical  examination  in,  469 
primary,  459 

symptoms  of,  465 
prognosis  of,  475 
proof  of,  461 
pyrosis  in,  466 
relation  of,  to  gall-bladder  diseases, 

578 
secondary,  459 

cause  of,  459,  462 
symptoms  of,  464 
gastric,  465 

negative,  467 
intestinal,  468 
negative  gastric,  467 
of  primary,  465 
treatment  of,  475 
dietetic,  479 
lavage  in,  478 
medical,  470 
variations  in,  461 
vomiting  in,  467,  469 
Hyperchlorhydria.     See  Hyperacidity. 


616 


INDEX 


Hyperesthesia,  545,  550 
gastric,  545 

clinical  types  of,  546 
with  gastralgia,  550 
Hypermotilit}'^,  562 
Hyperpeptic  gastritis,  47 
Hypersecretion,  510 
acute,  510 

constipation  in,  513 

course  of,  514 

diagnosis  of,  514 

duration  of,  514 

(kie  to  adherent  jjrepuce,  516 

to  ulcer,  515 
etiology  of,  510 
headache  in,  513 
pain  in,  511,  512 
prognosis  of,  516 
relation  of,  to  gastric  ulcer,  124 
to  locomotor  ataxia,  511 
to  pyloric  narrowing,   511, 
514 
symptoms  of,  511 
treatment  of,  516 
urine  in,  513 
vomiting  in,  512 
with  ai)pendicitis,  516 
with  cancer,  515 
alimentary,  472,  510,  530 
constipation  in,  534 
diagnosis  of,  535 
differentiated  from  larval  hj'per- 

acidity,  531 
emaciation  in,  533 
etiology  of,  530 
frequency  of,  533 
gastric  analysis  in,  535 
lavage  in,  536 
loss  of  weight  in,  533 
physical  signs  in,  535 
relation  of,  to  gastric  ulcer,  126 
symptoms  of,  533 
treatment  of,  536 
chronic,  517 

cancer,  ijyloric,  in,  521 
diagnosis  of,  527 
dilTcrenlial  diagnosis  of,  527 
diCferentiated  from  appendicitis, 
52S 
from    gall-bladder    disease 

and  gallstones,  528 
from  ulcer,  528 
etiology  of,  519 
frequency  of,  519 
gastric  analysis  in,  527 

juice  in,  517 
motor  error  in,  520 
causes  of,  521 
degrees  of,  520 
pain  in,  524 
patliology  of,  523 
f)rogn()sis  of,  528 
pylorospasm    and     appendicitis 
in,  521 
and  gallsfones  in,  521 


Hypersecretion,    chronic,    relation  of,  to 
gastric  ulcer,  126 
symptoms  of,  523 
treatment  of,  528 
lavage  in,  529 
ulcer,  pyloric,  in,  521 
urine  in,  524 
vomiting  in,  524,  528 
continuous,  472,  510 
differentiated  from  hyperacidity, 

459,  472,  531 
digestive,  510 
in  gastric  ulcer,  124,  126 
in  pyloric  stenosis,  355 
relation  of  ulcer  to,  515 


Ileal  kinks,  587 

Ileus,  arteriomesenteric,   333,   425.     See 
Dilatation,  acute, 
duodenal,  333.  See  Dilatation,  acute, 
mesenteric,   333.     See  Dilatation, 
acute. 
Indigestion,   gastric,   dififerentiated  from 
gall-bladder  disease,  577 
from  gallstones,  577 
nervous,  538.    See  Neuroses,  gastric, 
sensory. 
Infectious   gastritis,    24.     See   Gastritis, 

infectious. 
Insomnia  in  gastroptosis,  436 
Intestinal  obstruction,  differentiated  from 
perforation  of  gastric  ul- 
cer, 167 
from  volvulus  of  stomach, 
424 
stasis  in  duodenojejunal  kinks,  589 
Intussusception     complicating      visceral 
crises  of  erythemas,  598 
differentiated  from  visceral  crises  of 
erythemas,  599 
Isohemolysis  reactions  in  cancer,  263 


Jaundice  in  gallstones,  577 

in  phlegmonous  gastritis,  35 
in  toxic  gastritis,  39 

Jaworski's  paradoxical  dihitation,  395 

Jugulopubic  index,  439 


Kinks,  (hiodenal,  causing  (HIatation,  336 

ileal,  587 

Lane's,  587 
Klebs-LoefHer    bacillus    in    membranous 
gastritis,  28 


INDEX 


OV 


Landau's  cntoroptusis,  427 
Lane's  kinks,  587 
Lead  poisoning,  chronic,  602 
colic  in,  605 
diagnosis  of,  605 
pain  in,  604 
symptoms  of,  603 
treatment  of,  605 
Leather  bottle  stomach,  216 
Linitis    jjlastica,    76.      See    Cirrliosis    of 

stomach. 
Lipoma,  289 

Liver,    abscess    of,    differentiated    from 
phlegmonous  gastritis,  36 
cirrhosis  of,  differentiated  from  cir- 
rhosis of  stomach,  88 
involved  in  cancer  of  stomach,  244, 
269 
Living  creatures  in  stomach,  294,  297 
Lobar    pneumonia    differentiated     from 

perforation  of  gastric  ulcer,  166 
Locomotor  ataxia.    <S'ee  Tabes  dorsalis. 

relation    of    hypersecretion    to, 
511 


M 


Magenblase,  550 
Meiostagmin  reactions  in  cancer,  263 
Melena.     See  Hemorrhage. 
Mesenteric  constriction  as  cause  of  dila- 
tation, 335 
Methyl  alcohol,  poisoning  by,  27 
Motor  activity  of  stomach,  309 

neuroses,  561 
Myxoma,  292 


N 


Nausea  in  atony  of  stomach,  316 
in  appendicitis,  572 
in  gastric  ulcer,  acute,  112 
in  gastritis,  alcoholic,  71 
chronic  catarrhal,  51 
infectious,  26 
in  gastroptosis,  435 
Nephritis  complicating   visceral  crises  of 

erythemas,  598 
Nervous  indigestion,  538.    See  Neuroses, 

gastric,  sensory. 
Neurasthenia,  in  atony  of  stomach,  312 
Neuroses,  gastric,  538 

diagnosis  of,  539 
motor,  561 

hypermotility  in,  562 
perigastric  imrest  in,  561 
pyloric  insufficiency  in,  562 
rumination  in,  561 
secretory,      563.      See     Hyper- 
acidity, achylia  gastrica. 


Neuro.ses,  gastric,  secretory,  achylia,  563. 
See  Achylia  gastrica. 
treatment  of,  566 
hyperacidity,     563.         See 
Hyperacidity, 
sensory,  543 

aerophagia,  553 
disorders    of    appetite     in, 
543 
aeoria,  544 
anorexia,  544 

treatment  of,  565 
bulimia,  543 

treatment  of,  566 
cynorexia,  543 
epigastralgia,  548 

causes  of,  550 
eructations,  553 

treatment  of,  566 
flatulence,  550 

etiology  of,  551 
nervous,  553 
symptoms  of,  551 
gastralgia,  548 

causes  of,  550 
in  chlorosis,  549 
in   insane   and   feeble- 
minded, 549 
in  syphilis,  549 
occurrence  of,  548 
treatment  of,  566 
with  aerophagia,  550 
with  hyperesthesia,  550 
with  pneumatosis  ven- 
tricuh,  550 
gastrokenosis,  544 
hyperesthesia,  545,  550 
clinical  types  of,  546 
treatment  of,  566 
^'omiting,  554 
cerebral,  556 
cyclic,  558 

diagnosis  of,  560 
etiology  of,  558 
pathology  of,  559 
prognosis  of,  560 
symptoms  of,  559 
treatment  of,  561 
etiology  of,  554 
hysterical,  556,  557 
nervous,  556 

Erb's  j  uvenile  type 

of,  557 
hysterical  tj-pe  of, 

557 
Leyden's    periodi- 
cal tj'pe  of,  557 
treatment  of,  566 
types  of,  557 
periodical,      558.     See 

Vomiting,  cyclic, 
recurrent,      558.     See 

Vomiting,  cyclic, 
reflex,  554 
symptoms  of,  541 


618 


INDEX 


Neuroses,    gastric,    therapeutic    tests  of, 
.)-12 
Ireatnient  of,  564 

of  special  symj:)toms,  565 


Obstruction,  differentiated  from  acute 
dilatation,  348 
duodenal,  5S7 
duodenojejunal,  333.    A'ec  Dilatation, 

acute, 
gastrojejunal,  333.     See  Dilatation, 

acute, 
in  gastroptosis,  434 
Occult  blood.    See  Hemorrhages, 
in  cancer,  233 
in  gastric  ulcer,  132,  133 
Osteoma,  292 


Pain.       See     Epigastralgia,     gastralgia, 
hyperesthesia,  gastralgokenosis. 
in  appendicitis,  116,  568 
in  arteriosclerosis,  117,  582 
in  atony  of  stomach,  315 
in  cancer,  225,  227 
in  cirrhosis  of  stomach,  84 
in  diai)hragmatic  hernia,  405 
in  dilatation  of  stomach,  acute,  341 
in  duodenal  ulcer,  110,  116 
in  duodenojejunal  kinks,  588 
in  epigastric  hernia,  601 
in  erosions,  liemorrhagic,  195,  197 
in  gall-bladder  diseases,  117,  577,  578 
in  gallstones,  577,  578 
in  gastric  crises  of  tabes  dorsalis,  592 

ulcer,    113,    116,    119,    124,    125, 
169.    See  Ulcer,  gastric, 
acute,  109,  111,  112 
in  gastritis,  acute,  568 

alcoholic,  71 

catarrhal,  chronic,  52 

(lietclic,  20,  21 

infectious,  26 

l)hlegmonous,  34 

toxic,  39 
in  gastrojejinial  ulcer,  203 
in  gastroptosis,  434,  435 
in  hyi)eraci(iity,  465,  467,  472 
in   hypersecretion,   acute,    124,    125, 
511,  512 

(•lu'onic,  524 
ill  jejunal  ulcer,  203 
in  lead  poisoning,  chronic,  604 
in  perforation  of  gastric  ulcer,    161, 

165 
in  pyloric  stenosis,  354 
in  sarcoma,  282 
in  tuberculous  ulcers,  301 
in  ulcer,  gastric,  110,  301,  570 
ill  \()l\iiliis  of  stoiiKich,  422,  423 


Pancreatic     hemorrhage,      differentiated 

from  volvulus  of  stomach,  424 
Pancreatitis,  tlifferentiated  from  perfora- 
tion of  gastric  ulcer,  167 
Papilloma,  294 

Paradoxical  dilatation  of  Javvorski,  395 
Paratyphoid   bacillus  in  infectious    gas- 
tritis, 25 
Pelvis,  involvement  of,  in  cancer,  244 
Perforation,  due  to  volvulus  of  stomach, 
418 
in  cancer,  266 
in  sarcoma,  284 
in  tuberculosis  of  stomach,  301 
of  duodenal  ulcer,  158,  159 
of  gastric  ulcer,  157 

abscess  in,  164,  165 
acute,  159 

.symptoms  of,   161 
chronic,   165 
collapse  in,   162 
differential  diagnosis  of,  166 
differentiated  from   appen- 
dicitis, 167 
from     erythematous 

diseases,    167 
from  intest  inal  obst  ruc- 
tion, 167 
from  lobar  ))neumonia, 

166 
from  pancreatitis,    167 
from  pleuri-sy,  166 
from   rupture   of   gall- 
blatlder,  168 
extravasation  in,   163 
fatality  in,  162 
leukocytosis  in,   162 
pain  in,  161,  165 
peritonitis  in,  164 
pulse  in,  162 
rigidity  in,  162,   165 
shock  in,   162,   165 
subacute,  163 
symptoms  of,   161,   165 
temperature  in,  162 
treatment  of,  179,  190 
vomiting  in,  161,  165 
of  gastrojejunal  ulcer,  206 
of  jejunal  ulcer,  205 
Perigastric  abscess  in  cancer,  267 
glands  in\'olved  in  cancer,  243 
unrest,  561 
Perigastritis  accompanying   gastric  ulcer, 

168,   170 
Peristalsis  in  gastroptosis,  443 

in  infantile  pyloric  stenosis,  386 
in  i)vloric  stenosis,  354,  361 
Peritoneal    ab.sce.ss    differentiated      from 

l)hlegnionous  gastritis,  36 
Peritonitis  complicating  vLsceral  crises  in 
erythemas,  599 
due  to  volvulus  of  stomach,  419 
in  cancer,  2()(),  269 
in  ])erforati()n  of  gastric  ulcei',   H)4 
in  sarcoma,   2S  I 


INDEX 


019 


Peritonitis,  pcrloiiitivc,  I'ijjjidit y  in,   KiL' 
luhfrculoiis,  (lif'fcrciitiiitcd   tVoni   cir- 
rhosis ol'  stonKicli,  XS 
Phthisis  vcntriculi,    Ki 
Pk'uris}'  (Uffcrontiufcil     IVoin   pcit'onti  ion 

of  gas  trif  ulcer,  lOG 
Pneumatosis  ventrieuli   with    gastralgia, 

550 
Pneumonia  complicaterl  by  dilatation    of 
stomach,  338 
differentiated    from    jjcrforation    of 

gastric  ulcer,  10(5 
in  cancer,  270 
Pneumothorax  differentiated     from   dia- 
phragmatic hernia,  410 
Polyadenoma,  290 
Polyadenome  en  nappe,  291 
Polyneuritis  in  cancer,  270 
Polypi,  mucous,  290 
Postoperative    gastric    dilatation,     333. 
See  Dilatation,  acute, 
ileus,  differentiated  from  dilatation, 
acute,  343 
Preperitoneal  lipoma,  600 
Prepuce,  adherent,  relation  of,  to  hyper- 

.secretion,  516 
Pruritus  in  cancer,  236 
Ptomain   poisoning,    24.      Sec    Gastritis, 

infectious. 
Ptosis.     See  Gastroptosis. 
Pus.     See  Absce.ss. 

in  phlegmonous  gastritis,  34,  35 
in  membranous  gastritis,  30 
Pyloric  insufficiency,  562 

narrowing,    relation    of    hypersecre- 
tion to,  511,  514 
orifice,  cancer  involving,  240 
spasm.     See  Spasm,  pyloric, 
stenosis.     See  Pyloric  stenosis. 
Pyloro.spasm.     See  Spasm,  pyloric. 
Pyrosis  in  hyperacidity,  466 


R 


Regurgitation,  duodenal,  due  to  exces- 
sive fat  in  diet,  591 

Keichmann's  disease,  510.  See  Gastro- 
succorrhea. 

Retroperitoneal  glands  involved  in  can- 
cer, 243 

Retroperitonitis,  callous,  76.  See  Cir- 
rhosis of  stomach. 

Rigidity  in  perforation  of  gastric  ulcer, 
163,  165 

Rumination,  561 


Salomon's  test  in  cancer,  265 
Sarcoma,  277 

cachexia  in,  281 

diagnosis  of,  284 

differentiated  from  cancer,  285 


Sar'coiiiM,  duration  of,  2Nl 
fev(>r  in,  281 
fre(|uency  of,  277 
gastric  analysis  in,  282 
hematemesis  in,  282 
metastases  in,  280 
pain  in,  282 
pathology  of,  278 
perfoiation  in,  284 
peritonitis  in,  284 
I)hysical  signs  of,  283 
situation  of  the  growth,  279 
splenic  enlargement  in,  283 
.symptoms  of,  281 
general,  281 
local,  281 
tonsils  in,  284 
treatment  of,  285 
vomiting  in,  282 
Sclerosis  of  stomach,  76.      See  Cirrhosis 
of  stomach, 
submucosa,    with    chronic    gastritis, 
76.    See  Cirrhosis  of  stomach. 
Spasm,  pyloric,  346 
acute,  346 
and  appendicitis  in  hypersecretion, 

521 
and  gallstones  in  hypersecretion,  521 
chronic,  347 
etiology  of,  346 
in  gall-bladder  diseases,  578 
in  gallstones,  578 
reflex,  347 

appendix  dyspepsia  in,  348 
diagnosis  of,  347 
treatment  of,  348 
with  appendix  disease,  348,  349 
with  gall-bladder  disease,    347, 
349 
symptoms  of,  346,  347 
treatment  of,  348,  349 
vomiting  in,  346 

with  ulcer,  346.     See  Ulcer,  gastric. 
Splanchnoptosia,  426 
Splanchnoptosis,  426 
Stenose  meconne  du  pylore,  359 
Stenosis  of  cardia  in  cancer,  171 
pyloric,  349 

adhesions  as  cause  of,  351 
benign,  351 

differentiated    from    atony 
of  .stomach,  311 
from  cirrhosis  of  stom- 
ach, 87 
from  malignant,  371 
cancer  as  cause  of,  353,  366 
Chvostek's  phenomenon  in,  358 
cicatrix  from  ulcer  as  cause  of, 

351 
congenital,  381 
in  adults,  389 

symptoms  of,  391 
treatment  of,  391 
in  infants,  381.     See  Steno- 
sis, pyloi'ic  infant il(\ 


620 


INDEX 


Stenosis,  pyloric,  constipation  in,  356 

contraction  of  orifice  as  cause  of, 

351 
diagnosis  of,  363,  371 
diarrhea  in,  356 
dryness  of  tissues  in,  357 
etiology  of,  351 
Erb's  phenomenon  in,  358 
food  stagnation  in,  355 
following  gastric  ulcer,  170 
gastric  analysis  in,  363,  364 

in  benign  stenosis,  364 
in  cases  of  transition  of 
j)yloric     ulcer     into 
cancer,  370 
in  malignant  stenosis, 
368 
tetany  in,  357,  358 
liypersecretion  in,  355 
liyi^ertrophic,  76.    See  Cirrhosis 

of  stomach, 
in  syphilis  of  stomach,  307 
increased  peristalsis  in,  354 
infantile,  381 

etiology  of,  381 
pathology  of,  381 
peristalsis  in,  386 
physical  signs  of,  386 
jjrognosis  of,  387 
symptoms  of,  385 
time  of  onset  of,  385 
treatment  of,  388 
dietetic,  388 
drug,  389 
lavage  in,  388 
operative,  388 
tumor  in,  387 
vomiting  in,  385 
inspection  in,  361 
intermittent,  358 
latent,  358 
loss  of  weight  in,  356 
malignant,  353 

differentiated  from  benign, 

371 
gastric  analysis  in,  368 
mechanism  of,  349 
pain  in,  354 
palpation  in,  362 
pathognomonic  sign  of,  350 
peristalsis  in,  361 
physical  signs  of,  354,  361 
prognosis  of,  372 
radiographic  tliagnosis  of,  370 
result  of,  350 
size  of  stomach  in,  362 
starvation  in,  356 
stomach  stiffening  in,  361 
symptoms  of,  354 
syphilitic,  307 
succussion  in,  362 
thickening    of    pyloric,    wall    as 

cause  of,  351 
treatment  of,  373 
dietetic,  374 


Stenosis,  pyloric,  treatment  of,  drugs  in, 
377 
lavage  in,  376 
medical,  373 
operative,  379 
Trousseau's  phenomenon  in,  357 
tuberculous,  301 
tumor  in,  362 

as  cause  of,  351,  352 
urine  in,  357 
vomiting  in,  355 
with    tuberculosis   of    stomach, 
301 
Strangulation,  with  diaphragmatic  hernia, 

399 
Subacidity,  gastritis  with,  50 
Subphrenic  abscess,  164 

in  cancer,  267 
Supraclavicular    glands  in\-olved  in  can- 
cer, 243 
Syphilis  of  stomach,  303 

cirrhosis  due  to,  307 
differentiated  from  cirrhosis,  87 
forms  of,  304 
frequency  of,  303 
pathology  of,  303 
jjyloric  stenosis  in,  307 
treatment  of,  308 
tumor  in,  306 

diagnosis  of,  306 
ulcer  in,  304 

diagnosis  of,  306 
symptoms  of,  305 
Syphilitic  cirrhosis  of  stomach,  307 


Tabes  dorsalis.    See  Locomotor  ataxia. 

gasti'ic  crises  of,  591 
Temperature.    See  Fever. 

in  acute  dilatation  of  stomach,  342 
in  perforation  of  gastric  ulcer,  162 
Tetany,  gastric,  in  pyloric  stenosis,  357, 

358 
Tight-lacing  and  gastroptosis,  428 
Tonicity,  normal,  of  stomach,  309 
Toxicity  as  cause  of  acute  dilatation,  338 
Trousseau's    phenomenon  in  gastric  tet- 
any, 357 
in  pyloric  stenosis,  357 
Tryptophan  tests  in  cancer,  264 
Tuberculous  jiyloric  stenosis,  301 
Tuberculosis  of  stomach,  29S 
diagnosis  of,  302 
forms  f)f,  300 
frcfpiency  of,  298 
hemorrhage  in,  301 
mode  of  infection,  298 
pain  in,  .301 
perforation  in,  301 
prognosis  of,  302 
pyloric  stenosis  in,  301 

symptoms  of,  302 
symptoms  of,  300,  302 


INDEX 


()21 


Tuberculosis    of   .slonuich,   U-calincnt  of,    Ulcer, 
302 
dietetic,  302 
medical,  302 
operative,  302 
ulcers  in,  300 

hemorrhage  in,  301 
pain  in,  301 
perforation  in,  301 
symptoms  of,  300 
Tumors,  benign,  286,  292 

cause  of  atony  of  stomach,  314 

of  volvulus  of  stomach,  420 

in  infantile  pyloric  stenosis,  387 

in  pyloric  stenosis,  351,  352,  362 

syphilitic,  306 

Tj'rotoxicon,  infectious  gastritis    and,  25 

Tympanites  in  volvulus  of   stomach,  424 


Ulcer,  90 

acute  perforating.     See  Ulcer,   gas- 
tric, acute, 
as  cause  of  cancer,  223,  370 
of  hour-glass  stomach,  392 
of  pyloric  stenosis,  351 
carcinomatous,  155,  156,  157 
Cm-ling's,  209 

differentiated  from  dietetic  gastritis, 
22 
from  hyperacidity,  472 
from  hypersecretion,  528 
duodenal,    90.      See   Ulcer,    gastric; 
ulcer,     gastric,     acute;     and 
ulcer,  gastric  and  duodenal, 
age,  influence  of,  on,  97 
at  or  near  pylorus,  110 
compared  with  fissure  of  anus, 

105 
complicating  burns,  208 
differentiated  from  gastric  ulcer, 

111,  116 
end-results  of,  145 
etiology  of,  98 
frequency  of,  91,  93,  95 
healing  of,  109 
location  of,  94 
mimber  of,  95,  96 
.    pain  in,  110,  116 

differentiated  from  that  of 
gastric  ulcer,  116 
pathology  of,  105 
perforation  of,  158,  159 
physical  signs  of,  139 
prognosis  of,  145 
radiographic      examination     in, 

144 
sex,  influence  of,  on,  96 
size  of,  95 
follicular,  207 

following  gastrojejunostomy,  198 
gastric,  90.    See  Ulcer,  gastric,  acute; 
and  ulcer,  gastric  and  duodenal. 


gastric,  acute,  100.  <SVy'  UU-er, 
gastric;  ulcer,  gastric  and 
duodenal;  and  ulcer,  duo- 
denal. 

age,  influence  of,  on,  97 

at  or  near  the  pylorus, 
110 

diagnosis  of,  112 

differentiated  from  duode- 
nal ulcer.  111 

gastric  analysis  in,  112 

healing  of,  108 

hemorrhage  in,  130 

location  of,  94 

nausea  in,  112 

not  involving  the  pvlorus, 
112 

pain  in,  109,  111,  112 

pathology  of,  104 

perforation  of,  158.  See 
Perforation  of  gastric  ul- 
cer. 

physical  signs  of,  112 

prognosis  of,  146 

recurrences  of,  113 

sequela?  of,  113 

sex,  influence  of,  on,  96 

size  of,  94 

symptoms  of,  109 

treatment  of  189 

vomiting  in,  112 
adhesions  in,  168 
age,  influence  of,  on,  97 
and  duodenal,    90.    See    Ulcer, 
gastric;     ulcer,     gastric, 
acute;    and    ulcer,    duo- 
denal. 

age,  influence  of,  on,  97 

autodigestion  in,  101 

causes  retarding  healing  of, 
102 

end-results  of,  145 

etiology  of,  98 

frequency  of,  91 

healing  of,  108 

multiple,  96 

number  of,  95 

pathology  of,  103 

physical  signs  of,  139 

position  of,  93 

prognosis  of,  145 

relative  frequency  of,  93 

sex,  influence  of,  on,  96 

size  of,  94 

toxemic  theor}^  of,  100 
as  precursor  of  cancer,  223 
associated  with  pjdoric  spasm, 

346 
at  or  near  pylorus,  110 
autodigestion  in,  101 
bloodvessels,  relation  of,  to,  98 
chronic,  113 

adhesions  accompanying, 
168 
pain  in,  119,  169 


622 


INDEX 


Ulcer,  gastric,  chronic,  age  in,  97 

as  precursor  of  cancer,  153, 

155,  223 
cicatricial   contractions   in, 

170 
development   of  cancer  in, 

153,  155,  223 
hour-glass    contraction    in, 

171 
hyi)ersecretion  in,  124 
acute,  and,  124 
alimentary,  and,  126 
chronic,  and,  126 
])ain  with,  124,  125 
location  of,  93 
malignant  degeneration  of, 
153 
develoj)ment  of  changes 

in,  155 
stages  of,  154 
pain  in,  113,  124 

after  ingestion  of  food, 

120 
constant  gnawing,   121 
differential       diagnosis 

of,  116 
differentiated  from  that 
of  appendicitis, 
116 
of  arterial  sclerosis, 

117 
of  duodenal  ulcer, 

116 
of  gall-bladder  dis- 
ease, 117 
due  to  adhesions,   119, 
169 
to    reversed    peri- 
stalsis, 121 
during  deglutition,  120 
in  back,  119 
in  classical  pain  type, 

113 
in  irregular  pain  tvpe, 

lis 

in  left  inguinal  region, 
118 
pathology  of,  106 
perforation    of,     157.      See 
Peiforation      of     gastric 
ulc(>r. 
l)erigastritis  accompan3'ing, 
168 
l)rogrcssive,  170 
phlegmonous  gastritis  with, 

172 
prognosis  of,  146 
pyloric    stenosis    following, 

170 
size  of,  94 

stenosis  of  cardiac   end   of 
stomach  in,  171 
pyloric,  following,    170 
symptoms    of,    in    classical 
pitin  type,   1 13 


Ulcer,     gnstric,     chronic,    symptoms  of, 
in        hj^persecretion 
type,  124 
in  irregular  pain  tj^pe, 

118 
in  vomiting  type,  122 
treatment  of,  189 
types  of,  113 
vomiting  in,  122 
cicatricial  contraction  in,  170 
complications  of,  153 
differentiated    from    acute    gas- 
tritis, 22 
from  duodenal  ulcer,  1 1 1 
from  volvulus  of  stomach, 
424 
end-results  in,  145,  146 

of  medical  treatment,  145 
of  surgical  treatment,  151 
etiology  of,  98 
follicular,  207 
frequency  of,  91,  93,  95 
gastric  analysis  in,  135 
hematemesis  in,  128.    See  Ulcer, 

gastric,  hemorrhage  in. 
hemorrhage  in,  99,  127,  130,  187 
fatality  of,  130 
occult,  132,  187 

aloin  test  for,  133 
benzidin  paper  test  for, 
134 
test  for,  133 
guaiac  test  for,  134 
tests  for,  133 
source  of,  130 
types  of,  128 
visible,  128 
hvperaciditv  and,  135 
healing  of,  'l08 

causes  retarding,  102 
local  injuries,  relation  of,  to,  100 
location  of,  93 
acute,  94 
chronic,  93 
malignancv,  suspicious  signs  of, 

in,  238  ■ 
lUMlignant  degeneration  of,  153 
nioicna  in,  128,  131.     Ncr  Ulcer, 

gastric,  hemorrhage  in. 
number  of,  95,  96 
j)ain  in,  110 
I)athology  of,  103 
acute,  104 
chronic,  106 
perforation   of,    157.      See    Per- 
foration of  gastric  ulcer, 
perigastritis       accompanving, 

168,   170 
physical  signs  of,  139 
prognosis  of,  145 

under    medical    treatment, 
145 
surgical  treatment,  14K 
ra<liogr;ipliic  indications  in,  112, 
144 


INDEX 


(V2'A 


Ulcer,   fiawtric,    nulicjfiruphic    indicutioii.s 
of  penetrating  or  i)erf orating 
uleer,   144 
radiograph}'  of,   140 
rigidity  in,  139 
sex,  influenee  of,  on,  96 
size  of,  94 
tenderness  in,  139 
toxemic  theory  of,  100 
treatment  of,  172,  1S9 
abstinence  in,  173 
diet  in,  175 
enemas  in,  174 
external  applications  in,  172 
general,  172 
Lenhartz's,  180 
Lockwood's,  182 
von  Leube's,  179 
medical,  176 

general,   176 
individual,   179 
of  adhesions,  190,  191 
of    hemorrhage,    173,    177, 

185,  186,  187,  190 
of  hypersecretion,  187 
of  obstruction,  190 
of  occult  bleeding,  187 
of  pain,  179 
of  perforation,  179,  190 
of 'Special  symptoms,  177 
of  vomiting,  178 
rest  in,  172 

surgical,  indications  for,  189 
with  phlegmonous  gastritis,  172 
gastrojejunal,  198,  199,  201 
diagnosis  of,  205 
etiology  of,  202 
following     gast  r  o  i  e  j  u  nos  t  omy , 

198 
pain  in,  203 
perforation  of,  205 

into     anterior      abdominal 

wall,  206 
into  colon,  206 
prognosis  of,  206 
symptoms  of,  202 
treatment  of,  206 
in  syphilis  of  stomach,  304 
in  tuberculosis  of  stomach,  300 
indurated.  See  Ulcer,  gastric,  chronic 
jejunal,  198,  199 

diagnosis  of,  205 

etiology  of,  199,  201 

following     gastrojejunostomy, 

198 
pain  in,  203 
pathology  of,  199 
perforation  of,  205 

into      anterior     abdominal 

wall,  206 
into  colon,  206 
postoperative,  199 
prognosis  of,  206 
symptoms  of,  202 
treatment  of,  206 


Ucler,  medical.     Sec  I'lcr-r,  givstric,  acute. 

mucous.     See  L'lcer,  gastric,  acute. 

near  pylorus,  pain  in,  110 

pain  in,  570 

pyloric,  in  hypersecretion,  521 

phlegmonous    gastritis    accompany- 
ing, 172 

postoperative,  198 

relation  of,  to  cirrho.sis  of  stomach,  78 
to  hypersecretion,  528 

syphilitic,  304 

tuberculous,  300 

uremic,  208 
Ulcus  carcinomatosum,  157 
Umbilical  ring  in^■olved  in  cancer,  245 
Urine  in  cancer,  236 

in  gastritis,  infectious,  26 
toxic,  39 

in  hypersecretion,  acute,  513 
chronic,  524 

in  pyloric  .stenosis,  357 


Vasomotor  ataxia,  595 
Vegetable  balls  in  stomach,  294,  296 
Visceral  crises  in  erythemas,  595 
classification  of,  596 
cohc  in,  598 
diagnosis  of,  599 
differentiated    from  appen- 
dicitis, 599 
from  cohc,  599 
from     intussusception, 
599 
etiology  of,  596 
intussusception    complicat- 
ing, 598 
nephritis  complicating,  598 
peritonitis      complicating, 

599 
symptoms  of,  597 
treatment  of,  599 
Volvulus  antiperistalticus,  416 
of  stomach,  415 

advancing  wheel  type,  416 
anterior,  416,  417 
complicating     diaphragmatic 
hernia,  419 
hour-glass  contraction,  421 
degree  of  rotation  in,  417 
diagnosis  of,  424 
differentiated  from  gastric  dila- 
tation, 425 
from  gastric  ulcer,  424 
from  intestinal  obstruction, 

424 
from      pancreatic      hemor- 
rhage, 424 
direction  of  rotation  in,  417 
douleur  thoracique  in,  423 
effect  of,  418 
erosion  due  to,  418 
etiology  of,  419 
ga,stroptosis,  relation  of,  to,  422 


624 


INDEX 


Volvulus  of  stomach,  idiopathic,  421 

incomplete,  423 

infracolic,  417 

mechanism  of,  416 

muscular  rigidity  in,  424 

pain  in,  422,  423 

pai'tial,  423 

perforation  due  to,  418 

peritonitis  due  to,  419 

physical  examination    424       in, 

posterior,  416 

prognosis  of,  425 

retreating  wheel  type,  416 

supracolic,  416 

symptoms  of,  422 

trauma  causing,  421 

treatment  of,  425 

tumors  causing,  420 

tympanites  in,  424 

vomiting  in,  423 
peristalticus,  416 
Vomiting,  554 
cerebral,  556 
cyclic,  558 
Erb's  type  of,  557 
etiology  of,  554 
hysterical,  556,  557 
in  appendicitis,  575 
in  atony  of  stomach,  317 
in  cancer,  228,  230,  238,  268 
in  cirrhosis  of  stomach,  84 


Vomiting  in  dilatation,  acute,  of  stomach, 
341 
in  duodenojejunal  kinks,  588 
in  epigastric  hernia,  601 
in  gastric  crises  of  tabes  dorsalis,  592 

ulcer,  acute,  112 
chronic,  122 
in  gastritis,  alcoholic,  71 

catarrhal,  chronic,  52 

dietetic,  20 

infectious,  26 

membranous,  30 

phlegmonous,  34,  35 

toxic,  39 
in  hernia,  diaphragmatic,  405 
in  hyperacidity,  467,  469 
in  hypersecretion,  acute,  512 

chronic,  524,  528 
in  infantile  pyloric  stenosis,  385 
in  perforation  of  gastric  ulcer,   161, 

165 
in  pyloric  stenosis,  355,  385 
in  sarcoma,  282 
in  spasm,  pyloric,  346 
in  volvulus  of  stomach,  423 
Leyden's  type  of,  557 
nervous,  556 
periodical,  558 
recurrent,  558 
reflex,  554 
Vomitus  matutinus,  71 


